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Website (If applicable): Telephone: <br />\N \NI W SQU rclt_cs 1313de_G-51-17)F,c6 9-06t- (c)(1-155oc1 <br />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.sloov.orolEHD <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTOD <br />CFO Business Name: <br />5 au evidev_ p<E_E 5 i-to <br />CFO Physical Address: <br />gO7 1 N6Ei2!-4 V-12 <br />Owner Name Date: <br />K S 114- t+-1- 12 - 2-21- <br />CFO City: CFO Zip: <br />614 95-31,90 <br />Categories: <br />0 "Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: VY , <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 />RECEIVED <br />"Class A" Self Certification Checklist: <br />El Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />DEC 06 2024 <br />LINVIRONNIENTAL HEALTH <br />DEPARTMENT <br />MI Baked Goods „ Dried Pasta Honey D Popcorn/ <br />Popcorn Balls <br />[X1 Candy <br />Churros <br />Buttercream <br />Frosting/Icing* <br />Dried Mole Paste <br />LI Fruit Empanadas <br />fI Granola/Cereals <br />Cotton Candy <br />Dry Baking Mixes <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />Herb/Spice Blends <br />El Fruit Tamales/Pies <br />LI Seasoning Salt <br />0 Candied Apples <br />I Mustard El Vinegar <br />El Dried Grain Mixes D Fruit Butter** <br />0 Flat Icing D <br />Lii Pizzeles <br />D <br />Nut Mixes/Nut <br />Butters <br /> LI Donuts and <br />Waffles <br />Fried or Baked <br />El Trail, Mix/ Dried Fruit Dried Fruit <br />LP Caramel/Fudge <br />Salted <br />El Marshmallow <br />Bars* <br />Marshmallows/ <br />Ground <br />Chocolate <br />Jams/Jellies** <br />7.6/29/2023 CFO REG/PERMITTING FORM <br /> <br />Nosgto-13°1