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S A N ,1 Q A Q U I N Environmental Health Department <br />—COUNTY <br />Greatness grows here. <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Na�m�e` ` Date: ^1 <br />Y]I"J1 aL,4e,N L.OV �U�-Zc) 7011 f CAVx C,0 cb-VLI - /-u <br />CFO Physical Address: CFO City: CFO Zip: <br />20` 5 Wes)A06-ce Ly\. Mahle,Lca, ca 853310 <br />Websde (If applicable): Telephone: <br />1. Categories: <br />A "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 -borne illness. <br />3. "Class A" Self Certification Checklist: <br />oChecklist completed ("Class A" CFOs Only) <br />4. Products: <br />Please check the items you will be preparing and/or selling. <br />A Baked Goods ❑ Dried Pasta ❑ Honey <br />❑ <br />Candy <br />❑ <br />Churros <br />l� <br />"e <br />Buttercream <br />❑ <br />Frosting/Icing* <br />❑ <br />Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ <br />Dry Baking Mixes <br />❑ <br />Waffle Cones <br />l� <br />"e <br />Buttercream <br />❑ <br />Fondant/Gumpaste* <br />❑ <br />Herb/Spice Blends <br />❑ Fruit Tamales/Pies <br />❑ Seasoning Saft <br />❑ Cotton Candy ❑ Candied Apples <br />❑ Dried or Dehydrated ❑Dried Vegetarian - <br />Vegetables Based Soup Mixes <br />❑ <br />Mustard <br />❑ <br />Dried Grain Mixes <br />JA <br />Flat Icing <br />❑ <br />Pizzeles <br />E] <br />Mixes/Nut <br />Buffers <br />Butters <br />E] <br />Trail Mix/ Dried Fruit <br />❑ Dried Fruit <br />Popcorn Balls <br />Popcorn <br />❑ <br />Vinegar <br />❑ <br />Fruit Butter* <br />❑ <br />Ground <br />Chocolate <br />❑ <br />Jams/Jellies** <br />Fried or Baked <br />❑ <br />Donuts and <br />❑ <br />Waffles <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ Dried Fruit <br />Marshmallows/ <br />KNSalted <br />❑ Marshmallow <br />CarameVFudge <br />Bars* <br />❑ <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 />