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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT et r. n <br />1868 East Hazelton Avenue, Stockton, CA 95205-62*WkoCIVED <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.orq/EHD <br />COTTAGE FOOD OPERATIONS (CFO) NOV 25 2024 <br />REGISTRATION/PERMITTING FORM ENVIRONMENTAL HEALTH <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTC)ERMIT/SERVICES <br />CFO Business Name: Owner Name; Date <br />adle, .(xr‘C-(ri V\6,0 C171 <br />Lt <br />CFO Physical Address: CFO City: CFO Zip: <br />dJs40 W. LrcV,Ck <br /> <br />U12- (WA'S <br />Website (If applicable): Telephone: <br />(611 6)(p04-i- 0504 <br />Categories: <br />a "Class A" (Direct Sales Only) $186 0 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: <br />Foods containing 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 />El Baked Goods 0 Dried Pasta El Honey <br />Candy 0 Dry Baking Mixes E Mustard <br />LII Churros El Waffle Cones ID Dried Grain Mixes <br />[1] Buttercream LI Buttercream 0 Flat Icing Frosting/Icing* Fondant/Gumpaste* <br />E Dried Mole Paste 111 Herb/Spice Blends LI Pizzeles <br />LI Popcorn/ <br />Popcorn Balls <br />0 Vinegar <br />LI Fruit Butter** <br />LI Ground <br />Chocolate <br />E Jams/Jellies** <br />Fried or Baked <br />E Donuts and <br />Waffles <br />Nut Mixes/Nut El Fruit Empanadas 0 Fruit Tamales/Pies 1---1 <br /> Butters <br />111 Granola/Cereals El Seasoning Salt LI Trail Mix/ Dried Fruit E Dried Fruit <br />,--, Salted 111 Cotton Candy El Candied Apples 1_1 Caramel/Fudge <br />NOV 25 2024 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Marshmallows/ <br />E Marshmallow <br />Bars* <br />cro REG/PERMITTING FORM EHD 16-27 6/29/2023