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SAN J O A Q U I N Environmental Healt G artment <br /> . COUNTY <br /> Greatness grows here. SEP 0 6 2019 <br /> COTTAGE FOOD OPERATIONS CFO ENVIRONMENTAL HEALTH <br /> REGISTRATION/PERMITTING FORM PERMIT/SERVICES <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> (>>r�,1���C�"I ►�I 6� c '1 A\rK(A���\ C C'1,A2. <br /> CFO Physical Address: CFO City: CFO Zip: <br /> k 0 4 `i 1 L_o­ IS i-10- 64 ficin �� .-� 1 r'i <br /> Website(If applicable): Telephone: <br /> CA 1-E4 6 rl Cl 10 ('E 6>4 to r� I . c� r✓► ( � Ci C1 ) � C1 0 C, LP <br /> 1. Categories: <br /> { "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 filings 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 /> PL-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 E] Popcorn/ <br /> Popcorn Balls <br /> ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" <br /> Buttercream Buttercream Ground <br /> Frosting/IcingFondant/Gumpaste* Flat Icing ❑ Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ ❑ Donuts and <br /> Butters Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples ❑ ❑ Marshmallow <br /> Caramel/Fudge Bars* <br /> Dried or Dehydrated Dried Vegetarian- <br /> ❑ Vegetables E] Dried <br /> Soup Mixes F-1 Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />