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Owner Name:Date: <br />Laurel Boyd <br />CFO City: <br />Stockton <br />Website (If applicable):Telephone <br />1. Categories: <br />S □"Class A" (Direct Sales Only) $186 “Class B” (Direct & Indirect Sales) $486 <br />2. Prohibited Items: <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 />0 □□□HoneyBaked Goods Dried Pasta <br />□□ Vinegar□□MustardCandyDry Baking Mixes <br />□□□□ Fruit Butter**Dried Grain MixesChurrosWaffle Cones <br />□□□□Flat Icing <br />□ Jams/Jellies**□s □PizzelesDried Mole Paste Herb/Spice Blends <br />□□□Fruit Tamales/PiesFruit Empanadas <br />□□ Dried Fruits0Seasoning Salt Trail Mix/ Dried FruitGranola/Cereals <br />□□□Cotton Candy Candied Apples <br />i CFO REG/PERMITTING FORMEHD 16-27 6/29/2023 <br />Buttercream <br />Frosting/lcing* <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Buttercream <br />Fondant/Gumpaste* <br />Salted <br />Caramel/Fudge <br />Nut Mixes/Nut <br />Butters <br />Popcorn/ <br />Popcorn Balls <br />Ground <br />Chocolate <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 Zip: <br />95204 <br />CFO Business Name: <br />LB's Bitchin1 Kitchen <br />CFO Physical Address: <br />2504 W Monterey Avenue <br />Fried or Baked <br />□ Donuts and <br />Waffles <br />Marshmallows/ <br />□ Marshmallow <br />Bars* <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.