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0 Honey <br />Mustard <br />Dried Grain Mixes <br />Flat Icing <br />Pizzeles <br />Nut Mixes/Nut <br />Butters <br />Salted <br />Caramel/Fudge 0 <br />SAN JOAQUIN <br />PAYMENT <br />COUNTY, <br />RECEIVED"reame" qr"Ic <br />Environmental Health Department <br />RECRVET) he <br />JUN 2 4 2022 <br />SAN JOAQUIN COUNTY <br />; ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />COTTAGE FOOD OPERATIONS (CFO) <br /> <br />JUN 2 4 2022 <br />REGISTRATION/PERMITTING FORM ENVIRONMENTAL HEALTH <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO))P ERMIT/SERVICES <br />CFO Business Name: Owner [lame: ose 0 r-P? 2— n R Ck LitVl Ofi <br />CFO Physical Address: <br />I 01f3P r1/4-1L A <br />CFO City: <br />late (Ck Lix; <br />; <br />(1 6 <br />pat -20 -22- <br />CFO Zik <br />VS2-`10 <br />Website (If applicable): <br />1. Categories: <br />-Class A" (Direct Sales Only) $155 <br />Telephone: <br />7 09 7f.) S5 S <br />0 "Class B" (Direct & Indirect Sales) $310 <br />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 />"Class A" Self Certification Checklist: <br />fkyi Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />I11" Baked Goods <br />Candy <br />Churros <br />Buttercream <br />Frosting/Icing* <br />Dried Mole Paste <br />D Fruit Empanadas <br />Granola/Cereals <br />Cotton Candy <br />D <br />Dried or Dehydrated <br />I—I Vegetables <br />0 Dried Pasta <br />Dry Baking Mixes <br />Waffle Cones <br />o Buttercream <br />Fondant/Gumpaste* <br />D Herb/Spice Blends <br />Fruit Tamales/Pies <br />Seasoning Salt <br />Candied Apples <br />D Dried Vegetarian- <br />Based Soup Mixes <br />Popcorn/ <br />Popcorn Balls <br />D Vinegar <br />Fruit Butter** <br />Ground <br />Chocolate <br />Jams/Jellies** <br />Fried or Baked <br />Donuts and <br />Waffles <br />0 Trail Mix/ Dried Fruit 0 Dried Fruit <br />Marshmallows/ <br />Marshmallow <br />Bars* <br />Vegetable and Potato Chips <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 J www.sjgov.org/EHD