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Owner Name: <br />e.)4A. <br />CFO City: <br />Telephone: <br />6'67- 2J 5 - 6 137 <br />Date: • <br />lo. <br />CFO Zip: <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.orq/EHD NED <br />1868 East HazeIton Avenue, Stockton, CA 95205-623 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />JUL 18 2024 <br />COTTAGE FOOD OPERATIONS (CFO) EniviRoNw„ -,.TAL HEALTI4 REGISTRATION/PERMITTING FORM PERM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />El Honey El <br />Ground <br />Chocolate <br />Fried or Baked <br />Donuts and <br />Waffles <br />Nut Mixes/Nut <br />Butters El Fruit Tamales/Pies <br />El Seasoning Salt <br />0 Candied Apples El <br />Salted <br />Caramel/Fudge <br />Popcorn/ <br />Popcorn Balls <br />0 Mustard El Vinegar <br />El Dried Grain Mixes El Fruit Butter** <br />1=I Flat Icing El <br />El Pizzeles El Jams/Jellies** <br />El <br />l Trail Mix/ Dried Fruit El Dried Fruit <br />Marshmallows/ <br />CI Marshmallow <br />Bars* <br />El Baked Goods El <br />Candy El <br />El Churros El <br />El Buttercream El Frosting/Icing" <br />El Dried Mole Paste LI <br />El Fruit Empanadas <br />El Granola/Cereals <br />El Cotton Candy <br />Dried Pasta <br />Dry Baking Mixes <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />Herb/Spice Blends <br />• <br />CFO Business Name: <br />e>11. 5 \oa,tcrA coa <br />CFO Physical Address: <br />53 1/ Cc,g-01 5\- <br />Website (If applicable): <br />F o AXMAj I rD3A.4ii <br />1. Categories: <br />17)16141 r <br />El "Class A" (Direct Sales Only) $186 <br /> -K "Class B" (Direct & Indirect Sales) $486 <br />Prohibited Items: Initial if you agree to abide by the following: (43 0 <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 />El Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM