Sacramento County Cottage Food Permit Application by PermitDocsPrivate


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Countywide Services Agency                                                           Bradley J. Hudson, County
Environmental Management                                                    Ann Edwards, Chief Deputy County
Department                                                                                           Executive
                                                                             Val F. Siebal, Department Director
Environmental Health Division        County of Sacramento
John Rogers, Chief


CFO Business Name:                                                                          Date:

CFO Physical Address:                             CFO City:                                      CFO Zip:

Owner Name:                                   Owner Phone:                             Owner Cell:

Mailing Address (if different):                   Mailing City:                                  Mailing Zip:

Email Address:


TYPE OF PERMIT                                                        FEE                        PE
   Class A Cottage Food Operation-Registration                        $ 107.00                   1653

   Class B Cottage Food Operation-Permit                              $ 227.00                   1654

1. Categories:

     Class A (Direct Sales Only)                           Class B ( Direct & Indirect Sales)

2. Prohibited Items:                                                           I Agree:           Yes             No

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 (CFO). These are food items that do not require refrigeration to keep
them safe from bacterial growth that could be a cause of food-borne illness.

        10590 Armstrong Ave • Mather, California 95655 • phone (916) 875-8440 • fax (916) 875-8513 •
3. Products:
Please check the items you will be preparing and/or selling.

   Baked Goods:
   Without Cream,           Dried Pasta                Honey                    Popcorn
   Custard, or Meat
   Candy                    Dry Baking Mixes           Mustard                  Vinegar
   Churros                  Fruit Butter               Tortillas                Waffle Cones
   Dried Mole Paste         Herb Blends                Pizzelles                Jams/Jellies
   Cookies                  Fruit Tamales/Pies         Nut Mixes                Covered Non-
   Fruit Empanadas          Nut Butters                Dried Tea                Dried Fruit
                            Sweet Sorghum
   Granola/Cereals                                     Roasted Coffee           Trail Mix
   Pastries                 Preserves                   Other:     Contact EMD (916) 875-8440

Food descriptions:

4. Product Labeling:                                                 I Agree:      Yes          No

   •   The words “Made in a Home Kitchen” in 12-point type on the cottage food product’s
       primary display panel.
   •   The name commonly used for the food product or an adequately descriptive name.
   •   The name of the cottage food operation which produced the food product.
   •   The address of the cottage food operation which produced the food product.
   •   The registration or permit number of the “Class A” or “Class B” cottage food
   •   In the case of a “Class B” cottage food operation, the name of the county of the local
       enforcement agency that issued the permit number.
   •   The ingredients of the cottage food product in descending order of predominance by
       weight, if the product contains two or more ingredients.

                                 MADE IN A HOME KITCHEN
                                      Natural Granola
                                 The Grand Granola Company
                               123 H St, Sacramento, CA 95800
                                       Sacramento County EMD
                                         Permit # SR0000000
                      Ingredients: Oats, Wheat Germ, Almonds, Walnuts, Cranberries,
                      Honey, Canola Oil, Vanilla

5. “Class A” Self Certification Checklist:

         Checklist completed (“Class A” CFOs Only)

6. Water Source:
Please check what type of water source will be used in Cottage Food Facility

         Municipal Water                                      Private Well*

*Additional forms may be required if food is prepared from a home with a private well.

7. Disposal of Waste:
Where does your sink waste water go to?

         Public Sewer Service                                 Private Septic System

۰ In the event of septic system failure or plumbing problem, you are required to notify the
  Sacramento County Environmental Health Department immediately.

8. Employee:                                                                          I Agree:   Yes   No

I understand that I may not have more than one full-time equivalent cottage food employee,
not including a family member or household member of the cottage food operator, within the
registered or permitted area of a private home where the cottage food operator resides and
where cottage food products are prepared or packaged for direct, indirect, or direct and
indirect sale to consumers.
9.   Gross Annual Sales:                                                      I Agree:    Yes         No

I understand that I will lose my CFO status and will need to become permitted in a
commercial facility if my CFO business exceeds the following gross annual sales figures for
the calendar years in the following table:

      Calendar Year                                             Gross Annual Sales
      In 2013 ......................................................... $35,000
      In 2014 ......................................................... $45,000
      In 2015 and in subsequent years .................. $50,000

I, ___________________________, agree to notify the Sacramento County Environmental
Health Department prior to modifying my food list, type of operation, and/or method of
selling, distributing, or otherwise providing my CFO products to the consumer or retailers
regardless of whether or not the product is sold, consigned or given away.

Signature of Owner:

            Signature                                  Print Name                        Date

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