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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.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 <br />cAr nc-41 fehz Picxiccin DqKcry F6761/76 - <br />CFO Physical Address: CFO City: <br />/90 Z erla c4- 5-1-6 (.)c. 1--ct e <br />Date: <br />130/2? <br />CFO Zip: <br />5T 2 o3 <br />tk.) <br />Website (If applicable): Telephone: <br />2ô7) S71 'Jo 3V <br />Categories: <br />XV "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: PI) L <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 />V2( Baked Goods <br />El Candy <br />Churros <br />111 Buttercream <br />Frosting/Icing* <br />1=I Dried Mole Paste <br />El Fruit Empanadas <br />El Granola/Cereals <br />El Cotton Candy <br />El <br />El <br />El <br />El <br />CI <br />El <br />El <br />lj <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 />CI <br />El <br />El <br />11] <br />LI <br />CI <br />El <br />ri <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 />Li Popcorn/ <br />Popcorn Balls <br />LI Vinegar <br />El Fruit Butter** <br />Ground El Chocolate <br />El Jams/Jellies** <br />Fried or Baked <br />El Donuts and <br />Waffles <br />El Dried Fruit <br />Marshmallows/ <br />El Marshmallow <br />Bars* <br />EHD 16-27 8/8/2023 1 CFO REG/PERMITTING FORM