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Docusign 5nvelope 6601963D-OF4F-4EF1-8AB3-9A6520EF9ECD <br />ctp,04!fy.. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqoviorq/EHD <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: Date: <br />Ink and Flour sourdough Bakery mel ena Garcia <br />CFO Physical Address: CFO City: CFO Zip: <br />1221 W locust ST Lodi 95240 <br />Website (If applicable): Telephone: <br />Categories: <br />El "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 r _.. <br />Prohibited Items: Initial if you agree to abide by the following: L <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 />SAN JOAQUIN COUNTY <br />"Class A" Self Certification Checklist: <br />Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />El <br />LI <br />LI <br />0 <br />El <br />0 <br />LI <br />Baked Goods <br />Candy <br />Churros <br />Buttercream <br />Frosting/Icing* <br />Dried Mole Paste <br />Fruit Empanadas <br />Granola/Cereals <br />Cotton Candy <br />0 <br />0 <br />111 <br />E <br />ill <br />LII <br />El <br />111 <br />Dried Pasta <br />Dry Baking Mixes <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />Herb/Spice Blends <br />Fruit Tamales/Pies <br />Seasoning Salt <br />Candied Apples <br />LI <br />LIiI <br />0 <br />I II <br />0 <br />El <br />n <br />Honey <br />Mustard <br />Dried Grain Mixes <br />Flat Icing <br />Pizzeles <br />Nut Mixes/Nut <br />Butters <br />Trail Mix/ Dried Fruit <br />Salted <br />Caramel/Fudge <br />Popcorn/ <br />Popcorn Balls <br />El Vinegar <br />0 Fruit Butter*" <br />iii Ground <br />Chocolate <br />CI Jams/Jellies"* <br />Fried or Baked <br />LI Donuts and <br />Waffles <br />0 Dried Fruit <br />Marshmallows/ <br />El Marshmallow <br />Bars* <br />EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM