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Pte- Psi . �d <br />22- z.l <br />SAN J O A Q U I N Environmental Health <br />Department <br />RATIONS (CFO) 1 <br />COTTAGE FOOD OPE <br />REGISTRATIONIPERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Owner Name: Date: In I'� 1202! <br />CFO Business Name: g A N^ �ky b L <br />!�� P PA FooDS t_�C Dn L 1(` <br />CFO Physical Address: <br />CFO City: CFO Zip. <br />6600 V4 Cgu4'MDUt4TAIrsl HOUSE X153011 <br />Website (If applicable): Telephone: <br />www. 6anaxF000��uso1 Corn 510- %9�- °1127 <br />1. Categories: <br />[?"' "Class A" (Direct Sales Only) $155 <br />❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: S <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br />foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food Operation. <br />These foods include items that de not require refrigeration to keep them safe from bacterial growth that could be a <br />cause of food -borne illness. <br />3. "Class A" Self Certification Checklist: <br />Q Checklist completed ("Class A" CFOs Only) <br />4. Products: <br />Please check the items you will be preparing and/or selling. <br />Baked Goods <br />❑ <br />Candy <br />❑ <br />Churros <br />❑ <br />Buttercream <br />❑ <br />Frosting/icing* <br />❑ <br />Dried Mole Paste <br />❑ Fruit Empanadas <br />D Granola/Cereals <br />❑ Cotton Candy <br />❑ Dried Pasta <br />Cry Baking Mixes <br />❑ Waffle Cones <br />❑ Buttercream <br />Fondant(Gumpaste* <br />L�-- Herb/Sp;c' tilands <br />U Fruit Tamales/Pies <br />❑ Seasoning Salt <br />[J Candied Apples <br />Dried or DehydratedDried Vegetar:; rn <br />n vugetabirs I `) Based Soup Mixes <br />❑ Honey <br />Ll (Mustard <br />[Dried Grain Mixes <br />❑ Flat Icing <br />❑ <br />Popcorn/ <br />❑ <br />Popcorn Balls <br />❑ <br />Vinegar <br />❑ <br />Fruit Butter** <br />El <br />Nut MixesfNut❑ <br />Chocolate Chocolate <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies** <br />Fried or Baked <br />Nut MixesfNut❑ <br />Donuts and <br />Butters <br />Walties <br />❑ <br />trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />Marshmallows/ <br />171 <br />Salted <br />❑ <br />Marshmallow <br />Caramel/Fudge <br />Bars* <br />r] Vegetable and Potato Chips <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />a --k I� <br />