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o� <br /> o� SAN JOAQUIN COUNTY <br /> <'i ENVIRONMENTAL HEALTH DEPARTMENT <br /> - 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> C'�Cjpd•pM�•', Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sictov.orq/EHD <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: II Owner Name: Date: J <br /> I'^I �.t�Y�A� L:; ; ���Gxc�+nc;�1'��a - u�v�SoV1 �Z/ <br /> CFO Physical Address: CFO City: CFO Zip: <br /> Website(If applicable): Telephone: <br /> Z o A) 417- - a'3e <br /> 1. Categories: <br /> ❑ "Class A" (Direct Sales Only) $186 ,f "Class B" (Direct & Indirect Sales) $486 <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. <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-bome illness. R L C E I V E D <br /> 3. "Class A" Self Certification Checklist: <br /> ❑ Checklist completed ("Class A" CFOs Only) DEC 2 1 2023 <br /> ENVIRON NI ENTAL IILALTH <br /> 4. Products: DEPAIZ MINT <br /> Please check the items you will be preparing and/or selling. <br /> ❑ Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcom Balls <br /> Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> ❑ Buttercream ❑ Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing* Fond ant/G umpaste* Chocolate <br /> ❑ Dried Mole Paste ❑ Herts/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies 0 Butters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Saft ❑ 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 />