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Food Preparation Requirements (includes packaging and handling): Yes No 11. Hand washing is required immediately prior to handling foods and after engaging in ❑ ZI 22. 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. Q ❑ 13. All food ingredients used in the CFO products are from an approved source. ® ❑ 14. Potable water shall be used for hand washing, ware washing and as an ingredient. IN ❑ 15. Is your water source a private well? ❑ 91 a. If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district? ® ❑ a. If YES, what is the name of the system or district? City of Lodi During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or ® ❑ ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 18. Infants, small children, or pets are excluded from the kitchen. ® ❑ 19. Smoking is excluded. ® ❑ 20. Any person with a contagious illness shall refrain from work in the CFO. ® ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. ❑ ZI 22. 1 have attached a sample label. 0 ❑ 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. Cottag Food Operator Checklist completed and submitted by: 4 g Qt. LcwYa- l�lsct-l.� IZ !3 2.1 Signature Print Name ate EHD 16-26 12/27/2012 2 CFO CLASS A CHECKLIST