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SAN JOAQUIN <br />COON -v <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: Date: <br />Tbct� tAAC Lady Avis -w 021V_I2_0z2- <br />CFO Physical Address: CFO City: CFO Zip: <br />14221 P.W+ nr. C4 s72;4 <br />Website (If applicable): Telephone - <br />1. <br />hone: <br />?t- 4�`'Z-51o32 <br />1. Categories: <br />PC "Class K (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: Y_ <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 />Please check the items you will be preparing and/or selling. <br />Baked Goods ❑ Dried Pasta ❑ Honey <br />❑ Candy <br />❑ Churros <br />Buttercream <br />Frosting/Icing' <br />❑ Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ Cotton Candy <br />El Vegetables or Dehydrated <br />Vegetables <br />❑ <br />Dry Baking Mixes <br />❑ <br />Waffle Cones <br />ElButtercream <br />Flat Icing <br />❑ <br />Fondant/Gumpaste' <br />❑ <br />Herb/Spice Blends <br />❑ Fruit Tamales/Pies <br />❑ Seasoning Salt <br />❑ Candied Apples <br />❑ Dried Vegetarian - <br />Based Soup Mixes <br />❑ <br />Mustard <br />❑ <br />Dried Grain Mixes <br />❑ <br />Flat Icing <br />❑ <br />Piaeles <br />El <br />Mixes/Nut <br />Buffers <br />Butters <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Popcorn/ <br />Popcorn Balls <br />❑ <br />Vinegar <br />❑ <br />Fruit Butter" <br />El <br />Chocolate Chocolate <br />❑ <br />Jams/Jellies" <br />Fried or Baked <br />❑ <br />Donuts and <br />Waffles <br />❑ <br />Dried Fruit <br />ElSalted ❑ Marshmallows/ <br />Caramel/Fudge Marshmallow <br />Bars` <br />❑ 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 />