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SAN JOAQUIN <br />couNT , <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Owner Name: Date: <br />Ai\jUSH '---DS/1/ <br /> 0G og 2,c2/2_ <br />CFO City: CFO Zip: <br />in 00 Fr-t-i n Ho us e C15391 <br />Telephone: .--H 5° .1-C6 -- s-_3 <br />CFO Business Name <br />CAYES S ,/ NVJU <br />CFO Physical Address: <br />136g, S Pi. <br />Website (If applicable): <br />1. Categories: <br />gi "Class A" (Direct Sales Only) $186 LI "Class B" (Direct & Indirect Sales) $312 <br />Prohibited Items: Initial if you agree to abide by the following: 1"- <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods <br />that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. These <br />foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of <br />food-borne illness. <br />"Class A" Self Certification Checklist: <br />Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />D <br />LI <br />D <br />LI <br />LI <br />D <br />Baked Goods <br />Candy <br />Churros <br />Buttercream <br />Frosting/Icing* <br />Dried Mole Paste <br />Fruit Empanadas <br />Granola/Cereals <br />Cotton Candy <br />LI <br />LI <br />LI <br />D <br />D <br />ID <br />0 <br />Dried Pasta <br />Dry Baking Mixes <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />Herb/Spice Blends <br />Fruit Tamales/Pies <br />Seasoning Salt <br />Candied Apples <br />LI <br />D <br />CI <br />LI <br />LI <br />,—, 1_1 <br />1E1 <br />Ei <br />Honey <br />Mustard <br />Dried Grain Mixes <br />Flat Icing <br />Pizzeles <br />Nut Mixes/Nut <br />Butters <br />Trail Mix/ Dried Fruit <br />Salted <br />Caramel/Fudge <br />Popcorn/ LI Popcorn Balls <br />LI Vinegar <br />Fruit Butter** <br />Ground LI Chocolate <br />LI Jams/Jellies** <br />Fried or Baked <br />LI Donuts and <br />Waffles <br />0 Dried Fruit <br />Marshmallows/ LI Marshmallow <br />Bars* <br />1868 a Flazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F <br />209 464-0138 I www.sigov.org/ehd <br />