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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 ® L1ironing, any activity that contaminates the hands such as after using the toilet, coughing or 22. ❑ sneezing, eating or smoking. -N ❑ 12. Warm water, hand soap and dean towels are available for hand washing. ® ❑ 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. j2 ❑ 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? ❑ a. If YES, what is the name of the system or district? L��.r„o During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or ® L1ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 22. 1 have attached a sample label. 18. Infants, small children, or pets are excluded from the kitchen. -N ❑ 19. Smoking is excluded. E ❑ 20. Any person With a contagious illness shall refrain from work in the CFO. Ut ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. 15� ❑ 22. 1 have attached a sample label. 9 ❑ By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AS 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: feu X Y&mka-tlyn M Hofnov� Is -Z' Signature Print Name Date Made in a Home Kitchen Perk #12345 Strawberry Cheesecake Scone Blue Rose Bakery & Tea 1007 Mariners Cv. Lathrop, CA 95330 Ingredients: Enriched flour (bleached wheat flour, niadn, iron, thiamine mononitrate, riboflavin, enzymes, folic acid), cream cheese (pasteurized milk and cream, salt, carob bean gum, cheese culture), heavy cream (heavy cream, carrageenan), eggs, butter (pasteurized cream, natural flavor) sugar, strawberries, baking powder (oom starch, sodium bicarbonate, sodium aluminum suflate, monocalcium phosphate), salt. Contains: Wheat, Dairy, Eggs Net Wt. 2.3 oz. (66 g.)