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---CF-0—rhysical Address: <br />132- C AnPckiCR1e, N-116/a(e <br />CFO City: CFO Zip: <br />c4:1 q 2'1 <br />Salted <br />Caramel/Fudge El <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjcehd.com <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />14; Is KI`-f—che,r‘ c:/3c per eliorri_ Copt ve,f1"0—"G <br />.c 0 Business Name: Owner Name: Date: <br />LA 1, TA k <br />Website (If applicable): Telephone: <br />?-exr— 43c7ZZ <br />Categories: <br />1S, "Class A" (Direct Sales Only) $186 111 "Class B" (Direct & Indirect Sales) $312 <br />Prohibited Items: Initial if you agree to abide by the following: U^ k. <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-borne illness. <br />"Class A" Self Certification Checklist: <br />1:1 Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />Baked Goods El Dried Pasta <br />II] Candy <br />El Churros <br />Buttercream <br />Frosting/Icing* <br /> <br />El Dried Mole Paste <br /> <br />• Fruit Empanadas <br />El Granola/Cereals <br /> <br />El Cotton Candy <br />111 <br />Fruit Tamales/Pies <br />El Seasoning Salt <br />Candied Apples <br />CI Honey <br />Dried Grain Mixes <br />Flat Icing <br />El Pizzeles <br />El Nut Mixes/Nut <br />Butters <br />Popcorn/ <br />Popcorn Balls <br />ID Vinegar <br />CI Fruit Butter** <br />El <br />Jams/Jellies' <br />Fried or Baked <br />Donuts and <br />Waffles <br />Marshmallows/ <br />El Marshmallow <br />Bars* <br />El Dry Baking Mixes El Mustard <br />El Waffle Cones El <br />Buttercream <br />Fondant/Gumpaste* <br />El Herb/Spice Blends <br />Ground <br />Chocolate <br />El Trail Mix/ Dried Fruit 1=I Dried Fruit <br />END 16-27 6/27/22 1 CFO REG/PERMITTING FORM