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n P• SAN JOAQUIN COUNTY ' \e,.,j— f\42e&z � <br />� <br />x ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 4640138 Web: www.s*cehd.com <br />COTTAGE FOOD OPERATIONS (CFO) FJ(t 11050 <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name:Owner ame: Date: <br />Cat, -- 5 <br />eet X MMA Afaer t tfflIJ CF�-7 Lt-3-2� <br />CFO Physical Address: CFO City: CFO Zip: <br />qj iU Br771°s� Ln M1,41/h*i/7 htls-e iy �jS3 q / <br />Website (If applicable): Telephone: <br />to�q-2.q,l-Obbl�J <br />1. Categories: a \ r(Ncn cc r +e r 8 ,1 <:-z) <br />"Class A" (Direct Sales Only) $125 ❑ "Class B" (Direct & Indirect Sales) $250 <br />2. Prohibited Items: Initial if you agree to abide by the following: 1-90IF I <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. <br />3. "Class A" Self Certification Checklist: <br />❑ Checklist completed ("Class A" CFOs Only) <br />4. Products: <br />Please check the items you will be preparing and/or selling. <br />r�j <br />Baked Goods <br />❑ <br />Dried Pasta <br />❑ <br />Candy <br />❑ <br />Dry Baking Mixes <br />❑ <br />Churros <br />❑ <br />Waffle Cones <br />❑ <br />Buttercream <br />❑ <br />Buttercream <br />Frosting/Icing* <br />Fondant/Gumpaste* <br />❑ <br />Dried Mole Paste <br />❑ <br />Herb/Spice Blends <br />❑ Fruit Empanadas ❑ Fruit Tamales/Pies <br />❑ Honey <br />❑ Mustard <br />❑ Dried Grain Mixes <br />❑ Flat Icing <br />❑ Pizzeles <br />El Butters Mixes/Nut <br />Butters <br />❑ <br />Popcorn/ <br />Popcorn Balls <br />❑ <br />Vinegar <br />❑ <br />Fruit Butter** <br />❑ <br />Ground <br />Chocolate <br />❑ <br />Jams/Jellies** <br />Fried or Baked <br />Donuts and <br />Waffles <br />❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br />Salted Marshmallows/ <br />❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br />Bars* <br />EHD 1&27612912015 1 CFO REGIPERMrMNG FORM <br />F P 05_1%35 z <br />