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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 sigov orq/EHD <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />C_ko Business Name: <br />.k-1-ryt\--DeulLfibbNiA5 <br />CFO Physical Address: <br />CALA A ,A- <br /> <br />Owner Nane: <br />0 CFO City: <br />exp./ Date: <br />H( 1 -2- <br />CFO Zip: <br /> <br />s-3(0 <br /> <br />Website (If applicable): Telephone: <br />2-0 - <br />1. Categories: ' / 4444 al- • <br /> <br />ee54,v1 <br /> <br />Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />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-borne illness. <br />"Class A" Self Certification Checklist: <br />p Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />Baked Goods <br />El Candy <br />El Churros <br />F <br />CI Dried Mole Paste <br />El Fruit Empanadas <br />El Granola/Cereals <br />1=I Cotton Candy <br />CI Dried Pasta <br />1:1 Dry Baking Mixes <br />CI Waffle Cones <br />El Buttercream <br />Fondant/Gumpaste* <br />1:1 Herb/Spice Blends <br />1:1 Fruit Tamales/Pies <br />El Seasoning Salt <br />El Candied Apples <br />El Honey <br />El Mustard <br />CI Dried Grain Mixes <br />CI Flat Icing <br />El Pizzeles <br />CI Nut Mixes/Nut <br />Butters <br />El Trail Mix/ Dried Fruit <br />[—I Salted <br />Caramel/Fudge <br />El Popcorn/ <br />Popcorn Balls <br />CI vinegar <br />CI Fruit Butter** <br />El Ground <br />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 />Buttercream <br />Frosting/Icing* <br />END 16-27 6/29/2023 1 CFO REG/PERMITTING FORM <br />09116S0