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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.siqov.orq/EHD <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: <br />LteiCiID i e <br />CFO Physical Address: <br />'-i-Do s Oronce PtVen tA . <br />Owner Name: Date: <br />Sorcm LI ZO Oefh \Olden totirg lz/03Moaq <br />CFO City: CFO Zip: <br />LOOtA. CIS 2-6t 0 <br />Website (If applicable): Telephone: <br />(2.04 ) 747 Zal <br />Cateaories: <br />1E "Class A" (Direct Sales Only) $186 El "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: SN <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 />IRI7Checklist completed ("Class A" CFOs Only) <br />Products: <br />Please check the items you will be preparing and/or selling. <br />Nt/ Baked Goods <br />111 Candy <br />D Churros <br />E Buttercream <br />Frosting/Icing* <br />111 Dried Mole Paste <br />CI Fruit Empanadas <br />1E/ Granola/Cereals <br />111 Cotton Candy <br />III <br />111 <br />III <br />El <br />El <br />CI <br />C1 <br />111 <br />Dried Pasta <br />Dry Baking Mixes <br />Waffle Cones <br />Buttercream <br />Fondant/Gumpaste* <br />Herb/Spice Blends <br />Fruit Tamales/Pies <br />Seasoning Salt <br />Candied Apples <br />III <br />CI <br />El <br />111 <br />n <br />El <br />El <br />El <br />Honey <br />Mustard <br />Dried Grain Mixes <br />Flat Icing <br />Pizzeles <br />Nut Mixes/Nut <br />Butters <br />Trail Mix/ Dried Fruit <br />Salted El Caramel/Fudge <br />CI Popcorn/ <br />Popcorn Balls <br />111 Vinegar <br />III Fruit Butter** <br />El Ground <br />Chocolate <br />III Jams/Jellies** <br />Fried or Baked <br />111 Donuts and <br />Waffles <br />El Dried Fruit <br />Marshmallows/ <br />Marshmallow <br />Bars* <br />EHD 16-27 6/29/2023 1 CFO REG/PERMITTING FORM