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NoFood Preparation Requirements (includes packaging and handHng):Yes □ □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. □14. Potable water shall be used for hand washing, ware washing and as an ingredient. □15. Is your water source a private well? □a. If YES, have you completed testing for bacteria and nitrate? IS □ a. If YES, what is the name of the system or district? NoDuring the preparation, packaging or handling of CFO products: □ □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. Yes NoLabeling Requirements: □21. A copy of the label has been submitted to this Department for review and approval. □22. I have attached a sample label. Cottage Food Operator Checklist completed and submitted by: Print NameJ DateSign 2 CFO CLASS A CHECKLISTEHD 16-26 12/27/2012 13 13 S s 0 0 IM S 0 □ 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. 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 16. Is your water source a public water system or community services district? Yes 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.