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Salted <br />Caramel/Fudge <br />Marshmallows/ <br />LI Marshmallow <br />Bars* <br />El Vegetable and Potato Chips <br />— SANsJOAQUIN uki i COUNTY <br />Environmental Health Department <br />1.0407 <br /> Greatness grows herc <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: <br />Destiny's Sweet Treats Destiny Burgess <br />CFO Physical Address: CFO City: CFO Zip: <br />201 west Tokay st Lodi <br /> <br />95242 <br />Website (If applicable): Telephone: <br />(209) 371-7864 <br />Categories: <br />IZ "Class A" (Direct Sales Only) $155 0 "Class B" (Direct & Indirect Sales) $310 <br />Verffbed by pcifFiller <br />Prohibited Items: Initial if you agree to abide by the following: ph w 07/07/2041 <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 />"Class A" Self Certification Checklist: <br />gl Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />Baked Goods Dried Pasta 111 Honey Popcorn/ <br />Popcorn Balls <br />Candy 0 Dry Baking Mixes 0 Mustard 0 Vinegar <br />Churros 0 Waffle Cones 0 Dried Grain Mixes 0 Fruit Butter"* <br />El Buttercream El 0 Buttercream Flat Icing D Ground <br />Frosting/Icing* Fondant/Gumpaste* Chocolate <br />Dried Mole Paste 0 Herb/Spice Blends 0 Pizzeles ID Jams/Jellies""" <br />Fruit Empanadas Fruit Tamales/Pies Nut Mixes/Nut <br />Butters <br />Fried or Baked <br />LI Donuts and <br />Waffles <br />El Granola/Cereals 0 Seasoning Salt El Trail Mix/ Dried Fruit 0 Dried Fruit <br />Date: <br />LI Cotton Candy 111 Candied Apples <br />Dried or Dehydrated 1-7 Dried Vegetarian- <br />Vegetables 'I Based Soup Mixes <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com