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Nomm <br /> ,nvironmental Health Department <br /> SAN lOAQUIN <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATIONIPERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616r�(IGATTO))te Z1 <br /> 0 ,/� Owner Name" U` U <br /> ss Na & ` 1, <br /> CFO lc AdVss' <br /> �,1IVV(V'1t\` �lTelepho <br /> Website(If applicable): UC v <br /> 1. Categories: �Y ^Class B" (Direct&Indirect Sales)$310 <br /> ❑ "Class A" (Direct Sales Only) $155 `�j�j� <br /> Initial if you agree to abide by the following. <br /> zgLt <br /> 2. Prohibited Items: <br /> Foods containing cream, custard, or meat fillings are pote oveld foly aZd by aus and eCoOitage Food OperaoonY <br /> foods that are defined as "non-potentially hazardous" are app preparation _ <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 /> ❑ Checklist completed ("Class X 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 /> Popcorn Balls <br /> ❑ Candy Dry Baking Mixes ❑ Mustard ❑ v-ww <br /> ❑ Churros ❑ Waffle Cones ❑ Dried Uri Mixes ❑ Fruit Butter'- <br /> Buttercream Buttercream E) Flat Iof Ground <br /> ❑ Frosting/Icing* ElFondant/Gumpaste* ❑ <br /> Chocolate <br /> ❑ Dried Mole Paste -f lerb/Spice Blends ❑ PIZZB <br /> ❑ Jams/Jellies" <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Nut!s/Nut Fried or Baked <br /> Butt, ❑ Donuts and <br /> Waffles <br /> ElGranola/Cereals ❑ Seasoning Salt ❑ Tral Dried Fruit <br /> ❑ Dried Fruit <br /> Sal <br /> ElCotton Candy ❑ Candied Apples Elge ❑ <br /> CaFud Marshmallows/ <br /> Marshmallow <br /> Dried or Dehydrated Dried Vegetarian- <br /> Bars* <br /> Vegetables ❑ Based Soup Mixes ❑ Ve and Potato Chips <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468F 209 464-0138 I KWw sjgoV.org/EHD <br />