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0 Food Preparation Requirements (includes packaging and handling): Yes No 11. Hand washing is required immediately prior to handling foods and after engaging in any activity that contaminates the hands such as after using the toilet, coughing or ❑ sneezing, eating or smoking. 12. Warm water, hand soap and clean towels are available for hand washing. ❑ 13. All food ingredients used in the CFO products are from an approved source. 1/ ❑ 14. Potable water shall be used for hand washing, ware washing and as an ingredient. 1l u 15. Is your water source a private well? ❑ a. If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district? 4 ❑ a. If YES, what is the name of the system or district? CM of Sum" During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or Elironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 1 18. Infants, small children, or pets are excluded from the kitchen.p�CJ// El19. Smoking is excluded. L11 E]20. Any person with a contagious illness shall refrain from work in the CFO. IJ ❑ Labelinq Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. 22. 1 have attached a sample label. ❑ By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616 (Gatto), as it pertains to a "Class A" Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin County Environmental Health Department of any intended changes to the above statement. Cottage Food Operator Checklist completed and submitted by: 0ftWqAk4A1----" �[,nda RA� 6 1 U I Signature Print Name Date EHD 16-26 12/27/2012 CFO CLASS A CHECKLIST