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Q0S)2- Laver ",;CILIC•lisrTent0 Nd • <br />CFO Physical Address: CFO City: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www .siciov.ontr2 <br /> 4 2024 <br />COTTAGE FOOD OPERATIONS (CPO)' IRONINILIN FAL HEALTH <br />REGISTRATION/PERMITTING FORM RTMENT <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />Owner Name: Date: <br />Tni ei-eC71 V\l' S\< LO1r C \VD Gt n 1z14 <br />CFO Zip: <br />C.1 r51--Qi <br />Website (If applicable): Telephone: <br />Q,CP °In °I—na <br />Categories: <br />;21N "Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <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. <br />Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-borne illness. <br />"Class A" Self Certification Checklist: <br />El Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />CFO Business Name <br />;c4 Baked Goods >I. Dried Pasta <br />El Candy \K" Dry Baking Mixes <br />Churros El Waffle Cones <br />Buttercream Buttercream <br />Frosting/Icing* Fondant/Gumpaste* <br />):KDried Mole Paste Herb/Spice Blends <br />LI <br />El Honey <br />n Mustard <br />LI Dried Grain <br />El Flat Icing <br />1:1 Pizzeles <br />LI Popcorn/ <br />Popcorn Balls <br />El Vinegar <br />Mixes n Fruit Butter** <br />LI Ground <br />Chocolate <br />Jams/Jellies** <br />El Fruit Empanadas fl Fruit Tamales/Pies <br />CI Granola/Cereals LI Seasoning Salt <br />1:1 Cotton Candy LI Candied Apples <br />Nut Mixes/Nut <br />Butters <br />El Trail Mix/ Dried Fruit <br />Salted <br />Caramel/Fudge <br />Fried or Baked <br />El Donuts and <br />Waffles <br />El Dried Fruit <br />Marshmallows/ <br />El Marshmallow <br />Bars* <br />LI <br />EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM