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SANJOAQUIN <br />4 r <br />COUN -- <br />COTTAGE F( <br />(CALIFORNIA <br />Environmental Health Department <br />OPERATIONS (CFO) <br />NIPERMITTING FORM <br />DE FOOD ACT AB 1616 (GATTO)) <br />CFO Birinsss Name: I Owner Name: Dale: <br />Adris Cookie Co. A86ayin mw+mez 117122 <br />CFO Physical Address: CFO city. CFO 2p: <br />232s 6TQOYn Ave• StZ04-yon <br />Website (If applicable): <br />Telephone: <br />2ovi-411.5397 - - - -- - - - <br />1. Categories: <br />(� "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: %i'M <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 -home illness. <br />3. "Class A" Self Certification Checklist: <br />M Checklist completed ('Class A" CFOs Only) <br />4. Products: <br />Please check the items you will he preparing anrlfor selling. <br />® Baked Goods <br />❑ <br />Candy <br />❑ <br />Chunos <br />❑ <br />Buttercream <br />Frosting/Icing' <br />❑ <br />Dried Mole Paste <br />[I Dried Pasta <br />❑ <br />Dry Baking Mixes <br />❑ <br />Waffle Cones <br />❑ <br />Buttercream <br />Fondant/Gumpaste' <br />❑ <br />Herb/Spire Blends <br />❑ Fruit Empanadas ❑ Fruit <br />❑ Granola/Cereals [I Seasoning Salt <br />❑ Cotton Candy <br />❑ Candied <br />�iApples <br />E] Dried or Dehydrated <br />Vegetables <br />E] Dried Vegetarian - <br />Based Soup Mixes <br />El <br />❑ <br />Popcom/ <br />Popcorn Balls <br />❑ <br />Mustard <br />❑ <br />Vinegar <br />❑ <br />Dried Grain Mixes <br />❑ <br />Fruit Butter" <br />Flat Icing <br />❑ <br />Ground <br />Chocolate <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies" <br />11 <br />Mixes/Nut <br />❑ <br />FriedDonuor Baked <br />Butters <br />Butters <br />nd <br />Waffles <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />Salted <br />Marshmallows/ <br />❑ <br />Caramel/Fudge <br />❑ <br />Marshmallow <br />Bars* <br />❑ Vegetable and Potato Chips <br />- — " 7868 E. Razetton Aven ie Stockton Caliiomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwW.SjO0v.0fU[FHD <br />Qq-U51c-14�1 S <br />