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n 4lIN <br /> _� SAN JOAQUIN COUNTY o <br /> <i ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 yjgR Q <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sicehd.cor�n 2 <br /> fr,>l„ 42p16 <br /> COTTAGE FOOD OPERATIONS (CFO) �SF9vcFs�i <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: 5LOJiAA Wx VW/ Owner Name: �Iwrf% �V/� Date: <br /> CFO Physical Address: 95/ Cr vN�,rW /,A CFO City: L.MnbJ,�.1 CFO Zip: <br /> Website(If applicable): JJ��::// G /�tV�LY�Gv /t Telephone: •JITIny\03'33H� <br /> 1. Categories: <br /> ❑ "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: 10AL <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 /> 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 E] Dried Pasta E] Honey El Popcorn <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard 9 Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter** <br /> ❑ Buttercream ❑ Buttercream ❑ Flat Icing ❑ Ground <br /> Frosting/Icing* Fondant/Gumpaste* Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> E] Donuts and <br /> ❑ Fruit Empanadas ElFruit Tamales/Pies ElButters <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Marshmallows/ <br /> Salted <br /> ❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars* <br /> EHD 16-27 6/29/2015 1 CFO REG/PERMITTING FORM <br />