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SAN JOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> 1ppP <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING FORM <br /> (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br /> CFO Business Name: Owner Name: Date: <br /> Kuya's Cookies Michelle Zamora 4.1.22 <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 3255 Milton Jenson Way Tracy,CA 95377 <br /> Website(If applicable): Telephone: <br /> 510-512-5630 <br /> 1._(Categories: <br /> Ill "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: MZ <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 /> 0 Checklist completed ("Class A" CFOs Only) <br /> 4. Products: <br /> Please check the items you will be preparing and/or selling. <br /> Fx1 Baked Goods ❑ Dried Pasta ❑ Honey ❑ 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 /> E] Frosting/Icing* ElFondant/Gumpaste* El 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 ❑ gutters El 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- ❑ Vegetable and Potato Chips <br /> Vegetables Based Soup Mixes <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/EHD <br />