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,ar'Hlry;•sz 40 SAN JOAQUIN COUNTY '0� <br />3 ENVIRONMENTAL HEALTH DEPARTMENT <br />w <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.oro/ehd <br />r.�ax <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Date: <br />ZE5T CL -AS -T Tomi11�As lI g0hug <br />CFO Physical Address: CFO City: CFO Zip: <br />s4 E; W1N5"vi`► CT --Mfty 17S34 -C) <br />Website (If applicable): <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: J LT <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. <br />Products: <br />❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes ❑ Dried Fruit <br />❑ <br />Granola/Cereals <br />❑ Nut Butters ❑ Dried Tea ❑ Trail mix <br />❑ <br />a Sorghum <br />ElRoasted Coffee F-1Chocolate Covered Nonperishable Food <br />Please check the items you will be preparing and/or <br />selling. <br />❑ <br />Other: <br />❑ <br />Baked Goods <br />❑ <br />Dried Pasta <br />❑ <br />Honey <br />❑ <br />Popcorn <br />❑ <br />Candy <br />❑ <br />Dry Baking Mixes <br />❑ <br />Mustard <br />❑ <br />Vinegar <br />❑ <br />Churros <br />❑ <br />Waffle Cones <br />A <br />Tortillas <br />❑ <br />Fruit Butter" <br />❑ <br />Dried Mole Paste <br />❑ <br />Herb/Spice Blends <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies" <br />❑ <br />Fruit Empanadas <br />❑ Fruit Tamales/Pies ❑ Nuts/Nut Mixes ❑ Dried Fruit <br />❑ <br />Granola/Cereals <br />❑ Nut Butters ❑ Dried Tea ❑ Trail mix <br />❑ <br />a Sorghum <br />ElRoasted Coffee F-1Chocolate Covered Nonperishable Food <br />Sy <br />❑ <br />Other: <br />** <br />These items must comply with standards described in Pad 150 of Title 21 of the Code of Federal Regulations <br />http�t/www acressdata fda <br />gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch cfm?CFRPart=150 <br />EHD 16-27 1/8/2014 1 CFO REG/PERMITTING FORM <br />