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� r <br /> SANiJ0AQUIN Environmental Health Department <br /> _•a!' "I <br /> —COUNTY— <br /> Greatness grows here. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616(GATTO)) q " <br /> CFO BusinesaMyAs Nameas krTcElc,.► Owner Name: Date: <br /> PhMyA SAMUDRALA i <br /> I <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 2211 '5 NjeYe Da' 9111?U u%i i-hese 85391 <br /> Website(if applicable): ( J/A Telephone: <br /> Slo 5�- 6 z3z <br /> 1. CAtenorilev. <br /> 01*�"_Class A"(Direct Sales Only)$155 ❑ "Class B'(Direct&Indirect Sales)$310 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <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 do not require refrigeration to keep them safe from bacterial growth that could be a <br /> cause of food-bome illness. <br /> 3. "Class A"Self Certification Checklist: <br /> Checklist completed('Class A"CFOs Only) <br /> 4. Products: <br /> ,�P/ease check the items you will be preparing and/or selling. <br /> 4=-K Baked <br /> Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcom Balis <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> Buttercream Buttercream Ground <br /> El ❑ Fondant/Gumpaste' El Flat Icing 13Ground <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies`• <br /> E] Fruit Empanadas El Fruit Mixes/Nut Fried or Baked Fruit Tamales/Pies ❑ Butters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit <br /> Salted - Marshmallows/ - <br /> ❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars' <br /> ❑ Dried Dehydrated Dried Vegetarian- Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <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 /> PR(l51-t'lltg 0 <br />