Form CDPH8676 "Pet Food Processor License/Registration Application" - California

What Is Form CDPH8676?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8676 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8676 "Pet Food Processor License/Registration Application" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
PET FOOD PROCESSOR LICENSE/REGISTRATION APPLICATION
PLEASE COMPLETE THIS FORM FULLY—INCOMPLETE APPLICATIONS WILL BE RETURNED
See page 2 for instructions.
NEW APPLICANT
RENEWAL APPLICANT
OWNERSHIP CHANGE
RELOCATION PREVIOUS ADDRESS: __________________
1. Name of Firm
9. Business Operator (name and title)
2. DBA (List additional DBA’s on separate sheet if necessary.)
10. Business Telephone Number
11. Business 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)
7. Mailing Address (continued)
18. Website (URL)
8. City
State
ZIP Code
19. Interstate Commerce
Product Shipped
Product or Raw Materials Received
N/A
20. Type of Ownership
Individual/Sole Proprietorship
Partnership
Corporation
Limited Liability Company
Nonprofit
Other:__________________
21. Owner’s Name / Corporate Name (if applicable)
State of Incorporation
22. Owners’ or Officers’ Names and Titles
Owners’ or Officers’ Names and Titles
23. Type of Activity (check all that apply)
M—Manufacturing
R—Repacking
W—Warehousing
Y—Labeling
24. Pet Food Products Processed for Sale in the State of California:
Complete and Balanced Diet Products:
Dog
Cat
Bird
Fish
Other:_________________________
Treat / Snack Products:
Dog
Cat
Bird
Fish
Other:_________________________
Nutritional Supplement Products:
Dog
Cat
Bird
Fish
Other:_________________________
***
***
Please submit labels for any product sold in California with your application.
Other (describe):
Product labels are required to complete application processing.
LICENSE FEE:
$254.00
: CA DEPARTMENT OF PUBLIC HEALTH
MAKE CHECKS PAYABLE TO
(Fee is Non-Refundable)
See page 2 for mailing address.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
25. Signature of Applicant
Date
Print Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE.
License Number
Expiration Date
Date Received
Payment Type
Amount
$
Fund 0001
Page 1 of 2
CDPH 8676 (07/18)
State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
PET FOOD PROCESSOR LICENSE/REGISTRATION APPLICATION
PLEASE COMPLETE THIS FORM FULLY—INCOMPLETE APPLICATIONS WILL BE RETURNED
See page 2 for instructions.
NEW APPLICANT
RENEWAL APPLICANT
OWNERSHIP CHANGE
RELOCATION PREVIOUS ADDRESS: __________________
1. Name of Firm
9. Business Operator (name and title)
2. DBA (List additional DBA’s on separate sheet if necessary.)
10. Business Telephone Number
11. Business 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)
7. Mailing Address (continued)
18. Website (URL)
8. City
State
ZIP Code
19. Interstate Commerce
Product Shipped
Product or Raw Materials Received
N/A
20. Type of Ownership
Individual/Sole Proprietorship
Partnership
Corporation
Limited Liability Company
Nonprofit
Other:__________________
21. Owner’s Name / Corporate Name (if applicable)
State of Incorporation
22. Owners’ or Officers’ Names and Titles
Owners’ or Officers’ Names and Titles
23. Type of Activity (check all that apply)
M—Manufacturing
R—Repacking
W—Warehousing
Y—Labeling
24. Pet Food Products Processed for Sale in the State of California:
Complete and Balanced Diet Products:
Dog
Cat
Bird
Fish
Other:_________________________
Treat / Snack Products:
Dog
Cat
Bird
Fish
Other:_________________________
Nutritional Supplement Products:
Dog
Cat
Bird
Fish
Other:_________________________
***
***
Please submit labels for any product sold in California with your application.
Other (describe):
Product labels are required to complete application processing.
LICENSE FEE:
$254.00
: CA DEPARTMENT OF PUBLIC HEALTH
MAKE CHECKS PAYABLE TO
(Fee is Non-Refundable)
See page 2 for mailing address.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
25. Signature of Applicant
Date
Print Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE.
License Number
Expiration Date
Date Received
Payment Type
Amount
$
Fund 0001
Page 1 of 2
CDPH 8676 (07/18)
Pet Food Processor License/Registration Application Instructions
PLEASE PRINT OR TYPE 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
Pet Food Processor License or Registration 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 Pet Food Processor License or Registration for this location, and you are
renewing that license or registration. If this firm has changed location or ownership, please submit a new application for
licensure of the facility.
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.
Facility Address: Enter the number, street, city, state, and ZIP code for this facility location.
3–5.
6–8.
Mailing Address: Enter the full mailing address if different from the facility address.
9.
Business Operator: Enter the full name of the person who manages the operations of your business and their title.
Business Telephone Number: Enter the daytime business telephone number for your business.
10.
11.
Business FAX Number: Enter your business 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.
Correspondent: Enter the name of the person to contact for information regarding this application and their title.
14.
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.
Country: Enter the country where your facility is located if outside of the United States.
17.
18.
Website: Enter the website address for your business if applicable.
19.
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.
20.
Type of Ownership: Place an (X) in the box next to the appropriate legal description of the facility’s ownership.
21.
Corporate Name: Enter the corporate name if applicable. Enter the State of Incorporation if applicable.
22.
Owners’ or Officers’ Names: List the business owners’ or officers’ names and titles.
23.
Type of Activity: Place an (X) in the boxes next to each activity that occurs at this facility. Mark all that apply.
24.
Pet Food Products Processed For Sale: Place an (X) in the box adjacent to each type of pet food processed in this
facility that is offered for sale in California, and submit labels for each product with your application.
25.
Sign the application, enter date signed, print your name and title.
LICENSE FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE TO OTHER LOCATIONS OR ENTITIES
**
MAKE CHECK PAYABLE TO:
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
MAIL APPLICATION AND CHECK TO:
Regular Mail: California Department of Public Health
Overnight Mail: California Department of Public Health
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) 324-2170 if you have additional questions about this application.
Fund 0001
Page 2 of 2
CDPH 8676 (07/18)
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