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V <br />c\\ < \ ex f O'Vx-Q.ro . <br />1. Categories: <br />□□"Class B" (Direct & Indirect Sales) $486“Class A" (Direct Sales Only) $186 <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 />□□□ Dried Pasta□HoneyBaked Goods <br />□ Vinegar□□0 Dry Baking Mixes MustardCandy <br />□□ Fruit Butter**□ Waffle Cones□Dried Grain MixesChurros <br />□□□□Flat Icing <br />□0 Herb/Spice Blends0 PizzelesDried Mole Paste <br />00 Fruit Tamales/Pies0Fruit Empanadas <br />□0 Dried Fruit0 Seasoning Salt0 Trail Mix/ Dried FruitGranola/Cereals <br />00 Candied Apples0Cotton Candy <br />i CFO REG/PERMITTING FORMEHD 16-27 6/29/2023 <br />F^ooio^ <br />Owner Name: <br />Alexandria Romero <br />CFO City: <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 />Nut Mixes/Nut <br />Butters <br />Salted <br />Caramel/Fudge <br />Date: <br />12/2/25 <br />CFO Zip: <br />Tracy <br />Ground <br />Chocolate <br />Popcorn/ <br />Popcorn Balls <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 />- r\e&c0 e(\ <br />CFO Business Name: <br />Crumb House Bakery <br />CFO Physical Address: <br />580 W 4th St <br />Website (If applicable): <br />Fried or Baked <br />0 Donuts and <br />Waffles <br />Marshmallows/ <br />0 Marshmallow <br />Bars* <br />Tracy <br />Telephone: 51Q 266-2569 <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 />0 Jams/Jellies**