Information about http://www.dhs.ca.gov/fdb/local/pdf/DHS8597.pdf
State of California--Health and Human Services Agency …
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Created: Thu Dec 21 10:31:20 2006
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State of California--Health and Human Services Agency CLEAR FORM Department of Health Services
Food and Drug Branch
CANNERY LICENSE APPLICATION
PLEASE COMPLETE THIS FORM FULLY--INCOMPLETE APPLICATIONS WILL BE RETURNED
See Page 2 for Instructions.
NEW APPLICANT RENEWAL APPLICANT RELOCATION OWNERSHIP CHANGE OWNERSHIP AND LOCATION CHANGE
1. Name of Firm 9. Facility Operator (name and title)
2. DBA (List additional DBAs on separate sheet if necessary.) 10. Facility Telephone Number 11. Facility FAX Number
( ) ( )
3. Facility Address (number, street) 12. 24-Hour Emergency Telephone Number 13. E-Mail Address
( )
4. Facility Address (continued) 14. Correspondent (name and title)
5. City State ZIP Code 15. Correspondent Telephone Number 16. Correspondent FAX Number
( ) ( )
6. Mailing Address (if different or P.O. Box number) 17. Country (if other than United States) 18. FDA CFN or FEI Number
7. Mailing Address (continued) 19. Website (URL)
8. City State ZIP Code 20. Interstate Commerce
Product Shipped Product or Raw Materials Received N/A
21. Type of Ownership
Individual/Sole Proprietorship Partnership Corporation/Limited Liability Company Nonprofit Other_____________________
22. Corporate Name (if applicable) State of Incorporation
23. Owners' or Officers' Names and Titles Owners' or Officers' Names and Titles
24. Type of Products Canned Under State Inspection (check all that apply)
Animal Food Fish Olives Miscellaneous Vegetables and Specialties (describe): ____________________________________
25. Type of Retort Equipment or Processing (check all that apply)
Still Retorts Continuous Cookers Hydrostatic Units Aseptic Units pH Control Products Other: _________________
MAKE CHECKS PAYABLE TO: DEPARTMENT OF HEALTH SERVICES
LICENSE FEE: $235.51
See Page 2 for Mailing Address.
The Food and Drug Branch MUST BE NOTIFIED IMMEDIATELY of any changes in the above information as provided by California Health
and Safety Code, Section 112750.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
26. Signature Date
Print Name Print Title
PLEASE DO NOT WRITE BELOW THIS LINE
License Number Expiration Date Date Received Payment Type Amount
$
DHS 8597 (12/06) FY 06/07 Fund 3081 Index 4060 PCA 84955 Receipt Source 125700 Agency Source 48 Page 1 of 2
Cannery License Application Instructions
Please Type or Print Your Application.
New Applicant/Renewal Applicant: Place an (X) in the box next to New Applicant if your firm has not previously applied for a Cannery
License at this location while under the current ownership. Place an (X) in the box next to Renewal Applicant if your firm has already
obtained a Cannery License for this location and you are renewing that registration. If this firm has changed location, ownership, or both,
place an (X) in the box adjacent to the appropriate response.
1. Name of Firm: Enter the full name of business, corporation, company, or organization applying for licensure.
2. DBA: Enter any other name(s) your company is doing business as.
3.5. Facility Address: Enter the number, street, city, state, and ZIP code for this facility location.
6.8. Mailing Address: Enter the full mailing address if different from the facility address.
9. Facility Operator: Enter the full name of the person who manages the operations at this facility and their title.
10. Facility Telephone Number: Enter the daytime business telephone number of this facility.
11. Facility FAX Number: Enter the facility FAX number.
12. 24-Hour Emergency Telephone Number: Enter the telephone number to be called in the event of an emergency.
13. E-mail Address: Enter the facility e-mail address.
14. Correspondent: Enter the name of the person to contact for information regarding this application and their title.
15. Correspondent Telephone Number: Enter the daytime business telephone number of the contact person.
16. Correspondent FAX Number: Enter the daytime business FAX number of the contact person.
17. Country: Enter the country where your facility is located if outside of the United States.
18. FDA CFN or FEI: Enter your U.S. Food and Drug Administration Central File Number or Federal Establishment ID if known.
19. Website: Enter the website address for your business if applicable.
20. Interstate Commerce: Place an (X) in the boxes that correctly describe your business' receipt or distribution of products or materials
through or into interstate commerce.
21. Type of Ownership: Place an (X) in the box next to the appropriate legal description of the facility's ownership.
22. Corporate Name: Enter corporate name if applicable. Enter the State of Incorporation if applicable.
23. Owners' or Officers' Names and Titles: List the business owners' or officers' names and titles.
24. Type of Products Canned: Place an (X) in the box that best describes the category of products canned at this facility.
25. Type of Retort Equipment or Processing: Place an (X) in the box next to the type of retort or processing that this business will be
using under this license (check all that apply).
26. Sign the application, enter date signed, and print your name and title.
MAKE CHECKS PAYABLE TO: DEPARTMENT OF HEALTH SERVICES
MAIL APPLICATION AND CHECK TO:
Regular Mail: California Department of Health Services Overnight Mail: California Department of Health Services
Food and Drug Branch - Cashier Food and Drug Branch - Cashier
MS 7602 1500 Capitol Avenue, MS-7602
P.O. Box 997435 Sacramento, CA 95814
Sacramento, CA 95899-7435
Call the Food and Drug Branch at (916) 650-6500 if you have additional questions about this application.
DHS 8597 (12/06) FY 06/07 Fund 3081 Index 4060 PCA 84955 Receipt Source 125700 Agency Source 48 Page 2 of 2