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`n='` : SAN,�IQAQUIN <br />Environmental Health Department <br />—COUNTY— <br />=_ 'r <br />Greatness grows here. <br />CFO Business Name: <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Owner Name: <br />CFO Physical Address: CFO City: CFO Zip: <br />1.`1 at I^.. fot!2�0 5+ StocKto n x(520 <br />Website (If applicable): Telephone: <br />(ZdCI � V I, 7:10 1 <br />1. Catenories: <br />% "Class K (Direct Sales Only) $155 ❑ "Class B" (Direct & Indirect Sales) $310 <br />2. _Prohibited Items: Initial if you agree to abide by the following: 4 <br />Foods containing cream, custard, or meat fillings 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 />1r Checklist completed ("Class K CFOs Only) <br />4. Products: <br />Please check the items you will be preparing and/or selling. <br />% Baked Goods <br />❑ <br />Candy <br />❑ <br />Churros <br />El <br />Buttercream <br />Frosting/Icing* <br />❑ <br />Dried Mole Paste <br />❑ Fruit Empanadas <br />❑ Granola/Cereals <br />❑ Cotton Candy <br />❑ Dried Pasta <br />❑ <br />Dry Baking Mixes <br />❑ <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />❑ <br />Herb/Spice Blends <br />❑ Fruit Tamales/Pies <br />❑ Seasoning Salt <br />❑ Candied Apples <br />❑ Dried or Dehydrated ❑ Dried Vegetarian - <br />Vegetables Based Soup Mixes <br />❑ <br />Honey❑ <br />Popcorn/ <br />Popcorn Balls <br />❑ <br />Mustard <br />❑ <br />Vinegar <br />❑ <br />Dried Grain Mixes <br />❑ <br />Fruit Butter** <br />Flat Icing <br />❑ <br />Ground <br />Chocolate <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies** <br />Nut Mixes/Nut <br />Fried or Baked <br />El <br />El <br />and <br />Butters <br />Waffles <br />❑ <br />Trail Mix/ Dried Fruit <br />[I <br />Dried Fruit <br />Marshmallows/ <br />E]Caramel/Fudge <br />Salted <br />ElBay <br />hmallow <br />❑ Vegetable and Potato Chips <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />