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SAN J O A Q U I N Environmental Health Department COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING FORM (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) CFO Business Name: Owner Name: AA �2MMN t� go rim Date: i 5 -9-1- CFO Physical Address: —� CFO City: CFO Zip: 3'/29 U. 5 we -r- lid QComf rft 4s7a� Website (If applicable): Telephone: 1. Categories: ,r ❑ , : "Class A" f Direct Sales O;nly),$A 55 . [ •,; Glass B' (Direct $ Indirect Sales) $310 2. Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as "non potentially hazardous"'amapproved for pteparation•by a Cottege,Eobd Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food -borne illness. 3. "Class A" Self Certification Checklist: ❑ Checklist completed ("Class A" CFOs Only) 4. Products: Please check the items you will be preparing and/or selling. L;d Baked Goods ❑ Candy ❑ Churros ElButtercream Frosting/Icing* ❑ Dried Mole Paste ❑ Fruit Empanadas ❑ Granola/Cereals ❑ Cotton Candy ❑ Dried Pasta ❑ Dry Baking Mixes ❑ Waffle Cones ❑ Buttercream Fondant/Gumpaste* ❑ Herb/Spice Blends ❑ Fruit Tamales/Pies ❑ Seasoning Salt ❑ Candied Apples ❑ Dried or Dehydrated ❑Dried Vegetarian - Vegetables Based Soup Mixes [IHoney E) Popcorn Popcorn Balls ❑ Mustard ❑ Vinegar ❑ Dried Grain Mixes ❑ Fruit Butter** E]Flat Icing ElGround Chocolate ❑ Pizzeles Jams/Jellies** Nut Mixes/Nut Fried or Baked ❑ Butters ❑ Donuts and Waffles ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit Salted Marshmallows/ ❑ Caramel/Fudge ❑ Marshmalbw Bars* ❑ Vegetable and Potato Chips 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/EHD � V & 2,00