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p(2_ "2 -SOOSS^o <br />Date: <br />1. Categories: <br />□“Class A" (Direct Sales Only) $186 “Class B" (Direct & Indirect Sales) $486 <br />12. Prohibited Items: <br />4. Products: <br />Please check the items you will be preparing and/or selling. <br />□ □□□Baked Goods Dried Pasta Honey <br />□□□□ VinegarCandyDry Baking Mixes Mustard <br />□□□□ Fruit Butter**Dried Grain MixesChurrosWaffle Cones <br />□□□□Flat Icing <br />□□ Jams/Jellies**□□Herb/Spice Blends PizzelesDried Mole Paste <br />□□□Fruit Tamales/PiesFruit Empanadas <br />□□□ Dried Fruit□Granola/Cereals Seasoning Salt Trail Mix/ Dried Fruit <br />□□□Cotton Candy Candied Apples <br />1EHD 16-27 6/29/2023 CFO REG/PERMITTING FORM <br />Buttercream <br />Frosting/lcing* <br />Buttercream <br />Fondant/Gumpaste* <br />Salted <br />Caramel/Fudge <br />Nut Mixes/Nut <br />Butters <br />Ground <br />Chocolate <br />Popcorn/ <br />Popcorn Balls <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.org/EHD <br />CFO Business Name: <br />HftfH 6ATS <br />CFO Physical Address: <br />, TI06ADY <br />Website (If applicable): <br />___ Marshmallows/ <br />□ Marshmallow <br />Bars* <br />Fried or Baked <br />□ Donuts and <br />Waffles <br />3. “Class A” Self Certification Checklist: <br />□ Checklist completed (“Class A” CFOs Only) <br />Owner Name: <br />NlVAs <br />CFO City: <br />L ATHfiof <br />Telephone: <br />■^08- 306 - g-/ 3 2— <br />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 />t. <br />CFO Zip: ' <br />■