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SAN JOAQUIN <br />Name: <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Owner Namppa�: <br />a,.„(,\ ,4n.(,\ fl\s <br />Date: <br />CFO Physical Address: CPO city: CFO Zip: <br />1�Sl$ Cr,e lc oa - SADrJvn 9 S' -(L <br />Website (If applicable): Telephone: <br />SIB `110 S2.3) <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: <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT O D. Only <br />foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage od O eration. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth tha ould 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 />Please check the items you will be preparing and/or selling. <br />If Baked Goods ❑ Dried Pasta ❑ Honey <br />d Candy <br />❑ <br />Churros <br />Buttercream <br />52( <br />Frosting/Icing* <br />❑ <br />Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ Cotton Candy <br />❑ Dry Baking Mixes ` <br />❑ Waffle Cones <br />Buttercream <br />FondantIGumpaste* <br />❑ Herb/Spice Blends <br />❑ Mustard <br />❑ Dried Grain Mixes <br />❑ Flat Icing <br />❑ Pizzeles <br />Popcorn/ <br />ERI <br />Popcorn Balls <br />❑ Vinegar <br />❑ Fruit Butter** <br />E] Chocolate Chocolate <br />❑ Jams/Jellies** <br />Fried or Baked <br />❑ Fruit Tamales/Pies <br />❑gutters <br />Nut Mixes/Nut <br />ElDonuts <br />and <br />Waffles <br />❑ Seasoning Salt <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />Salted <br />Marshmallows/ <br />Candied Apples <br />1-1 <br />❑ <br />Marshmallow <br />Caramel/Fudge <br />Bars <br />Dried or DehydratedDried Vegetarian- <br />❑ Vegetables ❑ Based Soup Mixes E] 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 />