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0.^QgIN <br /> a *10, SAN JOAQUIN COUNTY <br /> W. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sigov org1EHD <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 /> t 1�IL' LQCk�S o r(�U h ,JCSSkCu MUCIW <br /> CFO Physical Address CFO City: CFO Zrp- <br /> l-1 3(0 CG..,nN-r C 1., �->-�oCk}Cv) 95Z04- <br /> Website(It applicable) Telephone: <br /> og- 40 c., --7G'Z 2 <br /> 1. Cateao_ ries: <br /> 2 'Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct 8 Indirect Sales) $486 <br /> { <br /> 2. Prohibited Items: Initial if you agree to abide by the following: �JM <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 bacter4 <br /> growth that could be a cause of food-borne illness. <br /> 3. "Class A" Self Certification Checklist: <br /> L;� Checklist completed ("Class A"CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing andlor selling. <br /> Lei Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> ❑ Buttercream ❑ Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing' FondantlGumpaste" Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ JamslJellies" <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ 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 16-27 W29=23 1 CFO RE&PERMITTING FORM <br /> [-rrc <br />