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® + SAN JOAQUIN Environmental Health Department <br /> f�MEIS /*_ _, ,urs—v <br /> brcotress g+o� <br /> MAY 18 2021 COTTAGE FOOD OPERATIONS (CFO) <br /> ENVIRONMENTAL HEALTH REGISTRATION/PERMITTING FORM <br /> PERMITISERVICt8ALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> Y S . Cnokie Com. ism Q__4�h 5Z1 /21 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 2 o w Map4_ s+. ( t5tokt pn q),2 o_y <br /> Website(If applicable): Telephone: <br /> Ks �voK iia C01 C� qm�� f cn�, (20�1�25b-lol�4�! <br /> 1. Categories: <br /> Uv "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: KS, <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 /> �y Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods El Dried Pasta [_1 Honey El 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 /> ElFrosting/Icing* ❑ Fondant/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 ElButters ❑ Donuts and <br /> WafFles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit <br /> Salted Marshmallows/ <br /> ❑ Cotton Candy ❑ Candied Apples ❑ Caramel/Fudge ❑ Marshmallow <br /> Bars* <br /> Dried or Dehydrated Dried Vegetarian- <br /> ❑ Vegetables ❑ Based Soup Mixes El Vegetable and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />