Form CDPH8642 "Shellfish Handling and Marketing Certificate Application" - California

What Is Form CDPH8642?

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 April 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 CDPH8642 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CDPH8642 "Shellfish Handling and Marketing Certificate Application" - California

595 times
Rate (4.8 / 5) 42 votes
State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
SHELLFISH HANDLING AND MARKETING CERTIFICATE 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 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)
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. Owner’s Name / Corporate Name (if applicable)
State of Incorporation
23. Owners’ or Officers’ Names and Titles
Owners’ or Officers’ Names and Titles
24. Type of Shellfish (check all that apply)
(check all that apply)
Fresh
Frozen
Oysters
Clams
Mussels
Scallops
25. Will any shellfish be held in a tank or body of water (wet storage)?
Yes
No
26. Will any shellfish you handle leave the state or be distributed to California dealers that will ship them out of state?
Yes
No
27. Who do you sell your product to? (check all that apply):
Wholesalers
Retailers (markets and/or restaurants)
Distributors
28. Will the shellfish be stored at your facility?
Yes
No
If no, location where stored: ____________________________
29. Please check the description that fits your shellfish activities at this facility:
Shellfish are depurated.
Shellfish are fully shucked and placed in containers.
Shellfish are shucked on the half-shell.
Shucked shellfish are repackaged from larger to smaller containers.
Shellstock is harvested and distributed.
Shellstock is repacked from larger to smaller containers.
Shellstock is stored and distributed in original containers.
NO FEE IS REQUIRED FOR THIS LICENSE.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
30. Signature
Date
Print Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE
License Number
Expiration Date
Date Received
Page 1 of 2
CDPH 8642 (04/18)
State of California—Health and Human Services Agency
California Department of Public Health
Food and Drug Branch
SHELLFISH HANDLING AND MARKETING CERTIFICATE 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 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)
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. Owner’s Name / Corporate Name (if applicable)
State of Incorporation
23. Owners’ or Officers’ Names and Titles
Owners’ or Officers’ Names and Titles
24. Type of Shellfish (check all that apply)
(check all that apply)
Fresh
Frozen
Oysters
Clams
Mussels
Scallops
25. Will any shellfish be held in a tank or body of water (wet storage)?
Yes
No
26. Will any shellfish you handle leave the state or be distributed to California dealers that will ship them out of state?
Yes
No
27. Who do you sell your product to? (check all that apply):
Wholesalers
Retailers (markets and/or restaurants)
Distributors
28. Will the shellfish be stored at your facility?
Yes
No
If no, location where stored: ____________________________
29. Please check the description that fits your shellfish activities at this facility:
Shellfish are depurated.
Shellfish are fully shucked and placed in containers.
Shellfish are shucked on the half-shell.
Shucked shellfish are repackaged from larger to smaller containers.
Shellstock is harvested and distributed.
Shellstock is repacked from larger to smaller containers.
Shellstock is stored and distributed in original containers.
NO FEE IS REQUIRED FOR THIS LICENSE.
By signature, I declare under penalty of perjury that all information provided herein is true and correct.
30. Signature
Date
Print Name
Print Title
PLEASE DO NOT WRITE BELOW THIS LINE
License Number
Expiration Date
Date Received
Page 1 of 2
CDPH 8642 (04/18)
Shellfish Handling and Marketing Certificate 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 Shellfish
Handling and Marketing Certificate 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 Shellfish Handling and Marketing Certificate for this location and you are renewing or updating information
for that certificate. If this firm has changed location or ownership, please submit a new application to obtain a certificate for this facility.
1.
Name of Firm: Enter the full name of business, corporation, company, or organization applying for a certificate.
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.
Business Operator: Enter the full name of the person who manages the operations of your business and their title.
10.
Business Telephone Number: Enter the daytime business telephone number for your business.
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.
14.
Correspondent: Enter the name of the person to contact for information regarding this application and their title.
Correspondent Telephone Number: Enter the daytime business telephone number of the contact person.
15.
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.
Interstate Commerce: Place an (X) in the boxes that correctly describe your business’ receipt or distribution of products or materials
20.
through or into interstate commerce.
Type of Ownership: Place an (X) in the box adjacent to the appropriate legal description of the business’ ownership.
21.
22.
Corporate Name: Enter the 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 Shellfish: Place an (X) in the box adjacent to the types of shellfish that your firm handles. Check all that apply.
25.
Shellfish Held in Wet Storage (Temporarily Store in Water): Answer yes or no by placing an (X) in the box adjacent to the correct
answer. This activity must be approved and permitted by CDPH-FDB before use.
26.
Shellfish Leaving the State or Distributed to California Dealers that Will Ship Them Out of State: Answer yes or no by placing
an (X) in the box adjacent to your answer. Interstate distribution of molluscan shellfish requires the dealers to be certified to the
Interstate Certified Shellfish Shippers List before distribution.
Who do you sell your product to: Check all that apply to your operation by placing an (X) in the box adjacent to the entity type that
27.
best describes your customers, ie. wholesalers, retailers, or distributors.
Shellfish Stored at Your Facility: Answer yes or no by placing an (X) in the box adjacent to your answer. If you answer “no”, enter
28.
the name and address of the firm where shellfish are held.
29.
Description That Fits Your Shellfish Activities: Place an (X) in the box adjacent to the description that fits your shellfish activities.
30.
Sign the application, enter date signed, and print your name and title.
MAIL APPLICATION 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.
Page 2 of 2
CDPH 8642 (04/18)
Page of 2