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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.slgov.org/ehd <br /> P.- <br /> COTTAGE FOOD OPERATOR REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CVk) i ess Narw-. Date: Y / <br /> /O o� `f <br /> CFO Physical Address: CFO City: CFO ZIP: <br /> Website(If applicable): <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) $125 ❑ "Class B" ( Direct& Indirect Sales) $250 <br /> /14 <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 /> ❑ Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods ❑ Dried Pasta ❑ Honey ❑ Popcorn <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Tortillas ❑ Fruit Butter— <br /> F1 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 <br /> ❑ Syrup F-1Roasted Coffee ❑ Chocolate Covered Nonperishable Food <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.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?CFRPart=150 <br /> EHD 16-27 12/27/2012 1 CFO REG/PERMITTING FORM <br />