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ZIP: 95377 CFO BUSINESS NAME: Mabu hay Grindz PHYSICAL ADDRESS: 1622 Dooston Ave. OWNER NA NI E: Russell and Christina Degala (ITV: Tracy County of Riverside DEPARTMENT OF ENVIRONMENTAL HEALTH www.rivcaehmrp, COTTAGE FOOD OPERATIONS (CFOs - Class A) SELF CERTIFICATION CHECKLIST The following requirements are outlined in the Collage Food Operations (('F0) regulations and are provided as minimum standards of health and safety for the preparation of approved cottage foods in the home. FOR OFFICE USE Facility Requirements: Yes No 1. The CFO is located in a private dwelling where the CFO operator currently resides ELI /. All CFO food preparation will take place in the private kitchen within that home. g El 3. Additional storage used for the CFO will be within the home. ID 0 If YES, is the room used exclusively for storage? Specify the room(s) that will be used for storage? Kitchen EI [2] 4. Sleeping quarters are exciuded from areas used for CFO food preparation or storage. El 0 Zoning Requirements: Yes No I have complied with the applicable zoning requirements for the CFO. I have attached documentation from the Planning office (If required) Employee and Training Requirements: Yes No 7. Have all persons preparing or packaging CFO products completed the CDPH food processor course? If YES, copies of certificates are attached. If NO, complete course within 3 months of CFO registration and forward a copy to the Environmental Health Office where registration was completed. 8. The CFO has no more than I full-time equivalent employee? (Immediate family or household members are not included.) Sanitation Requirements: 0 0 Yes No 9. Kitchen equipment and utensils used to produce CFO products are clean and maintained in a good state of repair. El 0 DES-13 (REV 9/161