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101K 06-q IS" <br /> ' SANdOAQUIN Environmental Health Department <br /> ' --COUN1-y_.._. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name <br /> CDate:: <br /> _ nt '� Ma�ctY . ,S r � ( �s,rn 2%ii_r, I1,3PiJ <br /> CFO Physical Address: CFO City' CFO Zip: <br /> :1 -4 Ll St SCA V1 v 61`533 } <br /> website(If applicable): `Thone: <br /> / LI'I — o <br /> tY S <br /> 1. Categories: <br /> DC '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: CT <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-borne illness. <br /> 3. "Class A" Self Certification Checklist: <br /> ❑ Checklist completed ("Class A"CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> 1tSl Baked Goods [I Dried Pasta El Honey C3 Popcorn <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> ® Buttercream ❑ Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing' Fondant/Gumpaste' Chocolate <br /> ❑ Dried Mole Paste ❑. Herb/Spice Blends ❑ Pi zzeles ❑ Jams/Jellies- <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Bunters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy E] Candied Apples ❑ Caramel/Fudge C] Marshmallow <br /> Bars' <br /> ❑ Dried or Dehydrated ❑ Dried Vegetarian- ❑ Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www,sjgov.org/EHD <br />