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Environmental Health Department <br />Food Preparation Requirements (includes packaging and handling):Yes No <br />12. Warm water, hand soap and clean towels are available for hand washing. <br />13. All food ingredients used in the CFO products are from an approved source. <br />14. Potable water shall be used for hand washing, ware washing and as an ingredient. <br />15. Is your water source a private well? <br />If YES, have you completed testing for bacteria and nitrate?a. <br />If YES, what is the name of the system or district?a. <br />During the preparation, packaging or handling of CFO products: <br />18. Infants, small children, or pets are excluded from the kitchen. <br />19. Smoking is excluded. <br />20. Any person with a contagious illness shall refrain from work in the CFO. <br />Labeling Requirements:Yes No <br />21. A copy of the label has been submitted to this Department for review and approval. <br />22. I have attached a sample label. <br />Cottage Food Operator Checklist completed and submitted by: <br />Signature <br />2 of 2 <br />CFO CLASS A CHECKLISTEHD 16-26 6/29/17 <br />17. Domestic activities such as family meal preparation, dishwashing, clothes washing or <br />ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. <br />11. Hand washing is required immediately prior to handling foods and after engaging in any <br />activity that contaminates the hands such as after using the toilet, coughing or <br />sneezing, eating or smoking. <br />0^? /x? <br />Date <br />SAN JOAQUIN <br />COUNTY— <br />Ma<4 <br />Print Name <br />By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616 (Gatto), as it <br />pertains to a "Class A" Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin <br />County Environmental Health Department of any intended changes to the above statement. <br />16. Is your water source a public water system or community services district? <br />Tmcij PvibGa <br />Yes No