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4r � <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.sIcIOv.O g/eird <br /> COTTAGE FOOD OPERATOR REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> Date. e71� `� <br /> CFO Business Name��� 6k�� p, �� C­,6,6 1 � ( <br /> / CFO City. <br /> � CFO ZIP. <br /> CFO Physical Address: <br /> �g � <br /> e_ I�C��� l� L� �p <br /> Website Of applicable): <br /> 1. Categories: <br /> __Ej-_�Class A"(Direct Sales Only) $125 ❑ "Class B" ( Direct& Indirect Sales) $250 <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. <br /> Only foods that are defined as"non-potentially hazardous"are approved for preparation by a Cottage Food <br /> Operation (CFO). These are food items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. "Class A" Self Certification Checklist: <br /> _F7-Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> ,_a--_&ked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ❑ Fruit Butter** <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes ❑ Dried Fruit <br /> ❑ Granola/Cereals ❑ Nut Butters ❑ Dried Tea ❑ Trail mix <br /> ❑ Sweet Sorghum ❑ Roasted Coffee ❑ Chocolate Covered Nonperishable Food <br /> Syrup <br /> ❑ Other: <br /> These items must comply with standards described in Part 150 of Title 21 of the Code of Federal Regulations <br /> http//www accessdata fda cov/scripts/odrh/cfdoes/cfCFR/CFRSearch.cfm2CFRPart=150 <br /> EHD 1627 12127/2012 1 CFO REGMERMITTING FORM <br />