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1318 0 5 040 <br /> ` SANaJOAQUIN Environmental .Health Department <br /> tY. —COUNTY— <br /> r <br /> rl".1 14 Grcotncs; grows hcrc. <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: I Owner Name: Date: <br /> 1ZAMYA S KTTcjGr4 gwM A SAMODRALA 01 tq 2022 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 1-1--1 -1 5 pude--e D?( M0L)1t)6;4) House 195391 <br /> Website(If applicable): Telephone: <br /> N�A 510 5 2!}- 62-32- . <br /> 1. Cate ories: <br /> Class A"(Direct Sales Only)$155 ❑ "Class B"(Direct.&Indirect Sales)$310 I <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <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 /> Checklist completed("Class A"CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Baked Goods ElDried Pasta ❑ Haney ❑ Popcorn/ <br /> Popcom Balls <br /> ❑ Candy [I Dry Baking Mixes ❑ Mustard ❑ Vinegar ' <br /> ❑ Chunos ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter' <br /> ❑ Buttercream ❑ Buttercream ❑ Flat Icing C] Ground <br /> Frosting/Icing Fondant/Gumpaste Chocolate <br /> ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies" <br /> Nut Mixes/Nut Fried or Baked <br /> ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ Donuts and <br /> Waffles <br /> ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/Dried Fruit ❑ Dried Fruit <br /> Marshmallows/ <br /> ❑ Catton Candy ❑ Candied Apples ❑ Salted ❑ Marshmallow <br /> Caramel/Fudge gars' <br /> ❑ Dried or Dehydrated Dried Vegetarian- Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> I <br /> -- 1866g. aze ton venue ':STo kCon, CalToirnag_ 'eDS l-T209�bE-�4ZG� F ��g hb t=01's8 I VAgW.slgeV.orgicriu ----- <br />