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°°SANPJQA0UIN Environmental Health Department <br />—COUNTY— <br />"_4wolts Greatness grows here. c <br />COTTAGE FOOD OPERATIONS (CFO) ��' / 00 2021 <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTC)r IR0tvtsEN ISI i ;"/,LTH <br />PERM!T/SERVICES <br />CFO Business Name: <br />Name: <br />rjI� Rm <br />Date: <br />03-31 –.ZO2 - <br />CFO Physical Address: CFO City: CFO Zip: <br />20D He1rlOom Ave. Ual) t4 91-7-y2 <br />Website (If applicable): Telephone: <br />h103zD-7o7o <br />1. Categories: <br />.K "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. Prohibited Items: Initial if you agree to abide by the following: <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br />foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food Operation. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br />cause of food -borne 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 />Baked Goods <br />❑ Candy <br />❑ Churros <br />Buttercream <br />Frosting/Icing* <br />❑ Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ Dried Pasta <br />[:1 DryBaking Mixes <br />❑ Waffle Cones <br />❑ Buttercream <br />Fonda nt/Gu mpaste* <br />❑ Herb/Spice Blends <br />❑ Fruit Tamales/Pies <br />❑ Seasoning Salt <br />❑ Cotton Candy ❑ Candied Apples <br />❑ Dried or Dehydrated ❑Dried Vegetarian - <br />Vegetables Based Soup Mixes <br />❑ <br />Honey <br />❑ <br />Popcorn/ <br />Popcorn Balls <br />❑ <br />Mustard <br />❑ <br />Vinegar <br />❑ <br />Dried Grain Mixes <br />❑ <br />Fruit Butter** <br />ElFlat <br />Icing <br />E]Ground <br />Chocolate <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies** <br />Nut Mixes/Nut <br />Fried or Baked <br />❑ <br />Butters <br />❑ <br />Donuts and <br />Waffles <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />Salted <br />Marshmallows/ <br />❑ <br />Caramel/Fudge <br />Marshmallow <br />Bars* <br />❑ Vegetable and Potato Chips <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />