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Date: CFC) EillSi ess Name: <br />uiffe <br />Owner Name <br />cr Lode, I+ (8. LLL <br />CFO City: CFO Physical Address: <br />152 t. 1 -•ItLqe.--14. Ave. <br />V257Z <br />CFO Zip: <br />qcjao <br />loSe <br />SAN JOAOUIN <br />C C)U N T <br />'less qr0,v,S here„ <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Website (If applicable): Telephone: <br />2o1 -?3 - .5337- <br />Categories: <br />cg. "Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: <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 />Pi Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />0 <br />El <br />LI <br />LI <br />El <br />LI <br />CI <br />0 <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 />El <br />CI <br />El <br />El <br />El <br />El <br />111 <br />El <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 />js Honey <br />El Mustard <br />El Dried Grain Mixes <br />El Flat Icing <br />El Pizzeles <br />Nut Mixes/Nut <br />111 Butters <br />II] Trail Mix/ Dried Fruit <br />ri Salted <br />Caramel/Fudge <br />Popcorn/ El Popcorn Balls <br />CI Vinegar <br />El Fruit Butter** <br />Ground CI Chocolate <br />El Jams/Jellies** <br />Fried or Baked <br />El Donuts and <br />Waffles <br />CI Dried Fruit <br />Marshmallows/ <br />El Marshmallow <br />Bars* <br />1868 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd