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sAti SAN JOAQUIN COUNTY <br /> <) ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • `� �'• Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sicehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date:/ <br /> �k1In- �Q rM 5 lGakiV)q M lc.hQ,II.F..�a-nhn OAL4 IM23 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 1`7035 t. k( tLoeo A-Vt-, on g53b(b <br /> Website(If applicable): Telephone: <br /> N /A a_0 CI -(01a-478`f <br /> 1. Categories: <br /> [d "Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $486 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: Ak-0— <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 /> 3. "Class A" Self Certification Checklist: <br /> ❑ Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter`s <br /> Buttercream Buttercream Ground <br /> Frosting/Icing* ElFondant/Gu mpaste* L] Flat Icing LlChocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies"` <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas Rr Fruit Tamales/Pies ❑ Butters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars <br /> EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM <br />