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A SAN JOAQUIN Environmental Health Department --COUNTY Asn Greatness a-- r i" COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING FORM (CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) CFO Business Name: Owner Name: Dat �wcirir !>CkN1 "Clic Surma c(,72]122 CFO Physical Address: CFO City: CFO Zip: j 212 San 900\o WU! _,�VoCy-koy� vll5209 Website (If applicable): Telephone: I r G- V G1 cl . 7 h -) 1 1. Categories: I �� "Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $312 2. Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as "non -potentially hazardous' are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food -borne illness. 3. "Class A" Self Certification Checklist: I� Checklist completed ("Class A" CFOs Only) 4. Products: Please check the items you will be preparing and/or selling. / [R' Baked Goods El Dried Pasta El Honey ❑ Popcorn/ Popcorn Balls ❑ Candy ❑ Dry Baking Mixes ❑ Mustard ❑ Vinegar ❑ Churros ❑ Waffle Cones ❑ Dried Grain Mixes ❑ Fruit Butter" ❑/ Buttercream dButtercream ❑ Flat Icing El Ground Frosting/Icing* Fondant/Gumpaste Chocolate ❑ Dried Mole Paste ❑ Herb/Spice Blends ❑ Pizzeles ❑ Jams/Jellies** Nut Mixes/Nut Fried or Baked ❑ Fruit Empanadas ❑ Fruit Tamales/Pies ❑ Butters ❑ Donuts and Waffles ❑ Granola/Cereals ❑ Seasoning Salt ❑ Trail Mix/ Dried Fruit ❑ Dried Fruit Salted Marshmallows/ ❑ Cotton Candy ❑ Candied Apples ElCaramel/Fudge El Marshmallow Bars` 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd