State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
ORGANIC PROCESSED PRODUCT 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 LOCATION ____________________
1. Name of Firm
9. Business Operator (name and title)
2. DBA (List additional DBAs 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. Product Type
Human Food
Cosmetics / Personal Care Products
Pet Food
Warehousing Only
Using a registered co-packer – Co-packer’s company name and registration number
24.
25. Type of Business
Handler (person who processes, packages, stores, or distributes)
Broker (does not take possession or title of product but arranges for its sale)
26. Annual gross sales or revenue from processing/handling organic processed products at this facility
$
Exempt from certification
27. Certification organization(s) or government entities certifying these product(s) as organic (attach additional sheets, if necessary)
Name
Address (number, street)
City
State
ZIP code
28. Payment Codes (Check only ONE payment code box A-I.)
29. Registration Fees
Enter Each Fee Below
Handler (See page 2 for fee schedule and instructions.)
$
A—$50
B—$100
C—$200
D—$300
E—$400
a. Registration Fee Due
F—$500
G—$600
H—$700
b. Penalty on Registration Fee
$
(1.5% per month if over 30 days late)
Broker (person who does not take possession or title of the product but only
arranges for its sale)
$
c. Total Payment Due
I—$100
MAKE CHECKS PAYABLE TO:
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
Fees are non-refundable
See Page 2 for Mailing Address.
NOTE: You must submit a completed Organic Processed Product Commodity Code List with your application.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
30. Signature
Date
Printed Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE
License Number
Expiration Date
Date Received
Payment Type
Amount
$
Fund 0177
Page 1 of 4
CDPH 8593 (07/18)
State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
ORGANIC PROCESSED PRODUCT 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 LOCATION ____________________
1. Name of Firm
9. Business Operator (name and title)
2. DBA (List additional DBAs 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. Product Type
Human Food
Cosmetics / Personal Care Products
Pet Food
Warehousing Only
Using a registered co-packer – Co-packer’s company name and registration number
24.
25. Type of Business
Handler (person who processes, packages, stores, or distributes)
Broker (does not take possession or title of product but arranges for its sale)
26. Annual gross sales or revenue from processing/handling organic processed products at this facility
$
Exempt from certification
27. Certification organization(s) or government entities certifying these product(s) as organic (attach additional sheets, if necessary)
Name
Address (number, street)
City
State
ZIP code
28. Payment Codes (Check only ONE payment code box A-I.)
29. Registration Fees
Enter Each Fee Below
Handler (See page 2 for fee schedule and instructions.)
$
A—$50
B—$100
C—$200
D—$300
E—$400
a. Registration Fee Due
F—$500
G—$600
H—$700
b. Penalty on Registration Fee
$
(1.5% per month if over 30 days late)
Broker (person who does not take possession or title of the product but only
arranges for its sale)
$
c. Total Payment Due
I—$100
MAKE CHECKS PAYABLE TO:
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
Fees are non-refundable
See Page 2 for Mailing Address.
NOTE: You must submit a completed Organic Processed Product Commodity Code List with your application.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
30. Signature
Date
Printed Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE
License Number
Expiration Date
Date Received
Payment Type
Amount
$
Fund 0177
Page 1 of 4
CDPH 8593 (07/18)
Organic Processed Product Registration 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 an Organic Processed Product
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 an Organic
Processed Product Registration for this location and you are renewing that registration. If this firm has changed location or ownership, please submit a new
application for registration for 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.
3.–5.
Facility Address: Enter the number, street, city, state, and ZIP code for this facility location.
Mailing Address: Enter the full mailing address if different from the facility address.
6.–8.
9.
Business Operator: Enter the full name of the person who manages the operations of your business and their title.
Business Telephone Number: Enter daytime telephone number for your business.
10.
11.
Business FAX Number: Enter your business FAX number.
24-Hour Emergency Telephone Number: Enter the telephone number to be called in the event of an emergency.
12.
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.
17.
Country: Enter the country where your facility is located if outside of the United States.
Website: Enter the website address for your business if applicable.
18.
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 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.
Product Type: Place an (X) in the box next to the type of product(s) that this firm handles or brokers (check all that apply).
24.
Using a Co-packer: Place an (X) in this box if you are using another registered firm to co-pack (process, package, or store) your organic products and
provide the firm name and registration number.
25.
Type of Business: Place an (X) in the box next to “Handler” if you process, handle, or warehouse organic products in this facility. Place an (X) in the
box next to “Broker” if you do not take possession or title of the organic product but arrange for the sale of the organic product.
26.
Annual Gross Sales or Revenue: This information will remain CONFIDENTIAL. Enter the total annual gross sales received from the sale of organic
processed product commodities or total revenue received for processing/handling organic products at this facility. Use the most recent 12-month
period for which you have records, or if none available, enter the projected gross revenue for the 12 months following the date of the registration
application.
27.
Certification Organizations: Enter the name(s) and addresses of certification organizations or government entities certifying these product(s) as
organic. If none, leave blank. If exempt from certification, check the box.
28.
Payment Codes: The registration fee is based on the gross annual sales or revenue of organic products (entered under item 25). Based on the chart
below, place an (X) in the appropriate box on the front page, next to the proper fee code.
Gross Annual Sales or Revenue
Annual Registration Fee**
A.
$0–$5,000
$ 50
B.
$5,001–$50,000
$100
C. $50,001–$125,000
$200
D. $125,001–$250,000
$300
E.
$250,001–$500,000
$400
F.
$500,001–$1,500,000
$500
G. $1,500,001–$2,500,000
$600
H. $2,500,001 and above
$700
I.
Broker Only***
$100
**
Any person that only provides temporary storage for seven days or less, or only provides transportation for organic product and does not handle the
organic processed product, does not have to register.
***
Broker means any firm that does not take possession or title of the product but arranges for the sale of the product.
29. a.
Registration Fee Due: Enter the amount checked under item 28 on the amount due line (a.). Fees are Non-Refundable.
Penalty on Registration Fee: A penalty of 1.5 percent per month is due if the payment is submitted more than 30 days after the due date (i.e., if paid
29. b.
more than 30 days after the date on the letter you received from the Department of Public Health, or if more than 30 days after the organic registration
renewal expiration date. A 1.5 percent per month penalty is due on the unpaid balance. To calculate the penalty due, see example below:
Computation Example: Due date 1/1/94. Date you actually submitted payment: 3/1/94 = 2 months late.
If registration fee is $100, multiply $100 x 1.5% – $1.50 penalty per month x 2 (months) = $3 total penalty due. Enter the penalty amount on the
Penalty on Registration line.
29. c.
Total Payment Due: Add penalty and registration fee together to determine total amount due. Enter this amount.
30.
Sign the application, enter date signed, and print your name and title.
NOTE: The required Organic Processed Product Commodity Code list must be completed and submitted with your application.
MAKE CHECKS 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 – MS 7602
Food and Drug Branch Cashier
P.O. Box 997435
1500 Capitol Avenue, MS 7602
Sacramento, CA 95899-7435
Sacramento, CA 95814
Call the Food and Drug Branch at (916) 327-3832 if you have additional questions about this application.
Fund 0177
Page 2 of 4
CDPH 8593 (07/18)
ORGANIC PROCESSED PRODUCT COMMODITY CODES
OPPR #
Check
Total Quantity
Total Quantity
all That
Measure
Handled
Brokered
Apply
Commodity
(30B)
(30C)
(30A)
Number
Commodity (Finished Products Only)
10
Soft Drinks, Carbonated and Noncarbonated; Water
Pounds
20
Beverage Bases, Liquid and Dry
Pounds
30
Coffee and Tea
Pounds
40
Alcoholic and Malt Beverages, Wines, Distilled Liquor
Pounds
50
Bread, Rolls, Buns, Sweet Goods, and Crackers
Pounds
60
Custard and Cream-filled Sweet Goods
Pounds
70
Macaroni and Noodle Products
Pounds
80
Breakfast Cereals, Ready to Eat
Pounds
90
Whole Grain and Beans, Bulk
Pounds
100
Pretzels, Chips, Tortillas, and Specialty Items
Pounds
110
Processed Grains and Starch Products For Human Use
Pounds
120
Prepared Mixes (Flour or Meal Based) Dry
Pounds
130
Candy, Chewing Gum, Chocolate and Cocoa Products
Pounds
140
Syrups, Sugars, Honey
Pounds
150
Butter and Butter Products
Pounds
160
Cheese and Cheese Products
Pounds
170
Fluid Milk and Fluid Milk Products
Pounds
180
Dried Milk and Dried Milk Products
Pounds
190
Ice Cream and Related Products
Pounds
200
Eggs and Egg Products
Pounds
240
Spices and Salt
Pounds
250
Extracts and Flavors
Pounds
260
Dressings and Condiments
Pounds
270
Fresh Fruits and Juices
Pounds
280
Frozen Fruits and Juices
Pounds
290
Canned Fruits, Juice Concentrates, and Nectars
Pounds
300
Dried Fruits
Pounds
310
Jams, Jellies, Preserves, and Butters
Pounds
320
Fruit Products including Olives
Pounds
330
Animal Feeds
Pounds
340
By-Products for Animal Feeds
Pounds
350
Meat and Meat Products
Pounds
360
Nuts and Nut Products
Pounds
370
Vegetable Oil Seed, Oil Stock, and Crude Oil
Pounds
380
Refined Vegetable Oil, Vegetable Shortening, and Margarine
Pounds
390
Fresh Vegetables
Pounds
400
Frozen Vegetables and Juices
Pounds
410
Canned Vegetables and Juices
Pounds
420
Dried and Dehydrated Vegetables
Pounds
430
Cured and Processed Vegetable Products, Tofu
Pounds
440
Dry Dessert and Pudding Mixes
Pounds
450
Multiple Foods, Pre-packaged Meals, Frozen Dinners
Pounds
460
Miscellaneous Food Use Items, Ice
Pounds
470
Multiple Food Warehouse
Pounds
480
Food Chemicals
Pounds
490
Infant, Junior, and Geriatric Foods
Pounds
500
Miscellaneous Dietary Food Items, Specialties, Sweeteners
Pounds
550
Vitamins, Other Nutritional Supplements
Pounds
910
Cosmetics
Pounds
Fund 0177
Page 3 of 4
CDPH 8593 (07/18)
Instructions for Completing the Organic Processed Products Commodity Codes
30A
Processed Product Commodity Codes: Review the Processed Product Commodity Code list, locate the code number of each organic processed
product commodity processed or handled at this facility and place an (X) in the column next to the commodity number. Commodities listed must be
finished products, not ingredients contained in products.
30B
Total Quantity of Each Processed Commodity Handled at This Facility: This information will remain CONFIDENTIAL. Enter the total quantity (in
pounds) of each finished product processed commodity that is Sold as Organic and annually handled and/or processed at this facility. A food is Sold
as Organic if the food, or one or more of its ingredients, is claimed to be organic. Use the most recent 12 month period for which you have records, or
if none available, enter the projected quantity to be handled in the 12 months following the date of registration.
30C
Total Quantity of This Product Brokered: This information will remain CONFIDENTIAL. Enter the quantity (in pounds) of this organic product
commodity that was arranged for sale, although never taken into possession or control by the broker.
NOTE: This list must be completed and submitted with your Organic Processed Product Registration Application.
All product quantities must be reported in pounds.
Fund 0177
4
Page 4 of
CDPH 8593 (07/18)
ADVERTISEMENT