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Date: <br />SAN JOAQUIN <br />—COUNTY <br />GrecItn , <br />rveecks <br />Environmental Health Department <br />12k o5Li <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: <br />Na_K -Dab h_kort 1-1a,y-f-vn <br />CFO Physical Address: CFO City: CFO Zip: <br />/b 3 3 rK 0 5 5 &- €-, -f-oci.k. fon 9 5?, & <br />Website (If applicable): Telephone: <br />1. Categories: <br />2v. "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: Dtp <br /> <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 />1:Kohecklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />CI Honey E Popcorn/ <br />Popcorn Balls <br />111 Mustard 0 Vinegar <br />111 Dried Grain Mixes 0 Fruit Butter** <br />0 Flat Icing 0 Ground <br />Chocolate <br />0 Pizzeles 10 Jams/Jellies** <br />Fried or Baked n Nut Mixes/Nut CI Donuts and Butters Waffles <br />0 Trail Mix/ Dried Fruit CI Dried Fruit <br />Marshmallows/ Salted 0 Marshmallow Caramel/Fudge Bars* <br />1868 E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />ET/ Baked Goods 0 Dried Pasta <br />1=1 Candy 0 Dry Baking Mixes <br />0 Churros 1=j Waffle Cones <br />111 Buttercream <br />Frosting/Icing* 111 Buttercream <br />Fondant/Gumpaste* <br />0 Dried Mole Paste 111 Herb/Spice Blends <br />1=1 Fruit Empanadas 1=1 Fruit Tamales/Pies <br />El Granola/Cereals 0 Seasoning Salt <br />LI Cotton Candy ID Candied Apples