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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 siqov.orq/EHD <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />,J0 <br />'/V1///i0 2024 <br />/V/I/F/V7;14.114. <br />CF Business Name: <br />‘n cic)c, <br />CFO Physical Address: <br />ccy P . <br />Website (If applicable): <br />A- <br />Categories: <br />.a---"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 />ZrChecklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />4-27 Baked Goods 1:1 Dried Pasta lE1 Honey LI Popcorn/ <br />Popcorn Balls <br />Owner Name: Date: <br />Ra WV\ tc" <br /> <br />CFO City: <br />rokt,A-ec'S' <br />Telephone: <br />LkLACL) \Q c)3 <br />CFO Zip: <br /> <br />El Candy <br />Churros <br />Buttercream <br />Frosting/Icing* <br />I=1 Dried Mole Paste <br />LI Fruit Empanadas <br />1::] Granola/Cereals <br />ID Cotton Candy <br />r] Dry Baking Mixes <br />El Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />p Herb/Spice Blends <br />rj Fruit Tamales/Pies <br />I:I Seasoning Salt <br />El Candied Apples <br />El Mustard 1:1 Vinegar <br />0 Dried Grain Mixes LI Fruit Butter** <br />1:::] Flat Icing LI <br />Pizzeles El Jams/Jellies** <br />Fried or Baked <br />El Donuts and <br />Waffles <br />Trail Mix/ Dried Fruit El Dried Fruit <br />Marshmallows/ 0 Marshmallow <br />Bars* <br />LI Ground <br />Chocolate <br />Nut Mixes/Nut <br />Butters <br />Salted <br />Caramel/Fudge <br />EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM <br />ppf 2 L( DD 2g