"Cottage Food License Application" - Georgia (United States)

Cottage Food License Application is a legal document that was released by the Georgia Department of Agriculture - a government authority operating within Georgia (United States).

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COTTAGE FOOD LICENSE APPLICATION
Gary W. Black
COMMISSIONER
GEORGIA DEPARTMENT OF AGRICULTURE • FOOD SAFETY DIVISION
19 MARTIN LUTHER KING JR DRIVE SW • ATLANTA, GA 30334
ESTABLISHMENT INFORMATION
WATER
NAME (Doing Business As)
SOURCE:
DISPOSAL:
Public
Public
(Municipal)
(Sewer)
CORPORATE NAME (If registered with the Secretary of State’s Office)
COUNTY OF RESIDENCE
Private
Private
(Well)
(Septic System)
STREET ADDRESS
CITY
STATE
ZIP
GA
RIGHT OF ENTRY
MAILING ADDRESS (If Different)
CITY
STATE
ZIP
GA
Pursuant to O.C.G.A. § 26-2-36(a), the Georgia
Department of Agriculture is authorized to have free
OWNER INFORMATION
access during all hours of operation and at all other
NAME
TITLE
reasonable hours to any establishment where food is
manufactured, processed, packed or held for introduction
PHONE
EMAIL ADDRESS
into commerce.
By completing this application, I understand the foregoing
TYPE OF OWNERSHIP
comprising the legal
ATTACH A LIST OF OWNERS AND OFFICERS
(Individual, Corporation, Partnership, Association, etc.)
ownership, including any Registered Agents, with the
and hereby grant the Department right of entry to the
following information:
residence, during the normal business hours, or at other
Names / Titles / Addresses / Phone Numbers
reasonable times, for the investigation of consumer
complaints, foodborne disease outbreaks, or other public
PREREQUISITES
health emergencies.
Indicate your
and
of these requirements by checking the following:
ACKNOWLEDGEMENT
COMPLETION
I understand that inspections due to consumer complaints
I have checked with my city and county governments, and there are no local ordinances that would
or foodborne illnesses investigations are required to be
prevent me from operating a home-based business.
conducted within one hour upon receiving notice of the
intent to conduct an investigation. I further understand that
I have checked with my local public utilities to ensure that my cottage food operations meet their
refusing entry of a Department representative, and any
approval for the existing sewage system, or I have checked with the local health department to ensure
my septic system is adequate for my intended operations.
additional investigators with appropriate credentials who
may accompany the Department for the purposes of
I have attached either a copy of my most recent water bill, or the lab results where I had my private
investigating consumer complaints or foodborne illnesses,
well tested for coliforms and nitrates.
shall be grounds for revocation of my Cottage Food
I have completed an accredited food safety training course, and a copy of my certificate is attached to
License.
this License Application.
COTTAGE FOOD OPERATOR RESPONSIBILITIES
VERIFICATION OF LAWFUL PRESENCE
Please initial by each statement acknowledging the
.
OPERATOR
S RESPONSIBILITIES
A
Notarized Affidavit
and acceptable documentation are
required by O.C.G.A. § 50-36-1.
• I have read and understand the Food Safety Directives contained in the Cottage Food
Regulations 40-7-19-.08.
Please notify us if you have previously submitted an
affidavit and one acceptable document for any other
INITIALS
license or GATE card issues by the Department.
• I understand that I can only make the Cottage Food Products listed on this application
This will allow us to search our databases and upload
form, and that the sales of these products can only be to the end consumer.
the required documentation for your new license and
enable a better customer service experience.
INITIALS
• I understand that I can only sell these products within the state of Georgia, and that I cannot
For assistance, call the Customer Service Center at:
ship my products across state lines without having first obtained a Food Sales
855-4-AG-LICENSE (855-424-5423)
Establishment License from the Georgia Department of Agriculture and registering with
the FDA according to the Bioterrorism Act.
ATTESTATIONS
INITIALS
By signing this document, the applicant:
• I understand that if I sell my products by weight that I have to use a scale that is legal for
1.
Attests that the information provided on this form is
trade, and that it is my responsibility to contact the Georgia Department of Agriculture to
accurate; and
have my scale certified annually.
2.
Affirms he/she will comply with Department laws and
INITIALS
regulations related to the operation of a cottage food
establishment.
COTTAGE FOOD PRODUCTS LIST
**PLEASE DO NOT SUBMIT PAYMENT
Indicate each
you intend to produce:
WITH YOUR APPLICATION**
TYPE OF PRODUCT
You will receive an email link to pay your license fee approximately
Breads, Rolls & Biscuits
Cakes & Cupcakes
two (2) weeks following your licensing inspection.
Candies & Confections
Cereals, Trail Mixes & Granola
Questions? Please see our website at:
Coated / Uncoated Nuts
Dried Fruits
http://www.agr.georgia.gov/cottage-foods.aspx
Dry Herbs, Seasonings & Mixtures
Fruit Pies
Contact us via phone:
Jams, Jellies & Preserves
Pastries & Cookies
Food Safety Division: 404-656-3627, or
Popcorn, Popcorn Balls & Cotton Candy
Vinegars & Flavored Vinegars
Licensing Division: 404-586-1411
APPLICANT – PRINTED NAME
APPLICANT – SIGNATURE
APPLICANT – TITLE
DATE
SAVE
SUBMIT
PRINT
COTTAGE FOOD LICENSE APPLICATION
Gary W. Black
COMMISSIONER
GEORGIA DEPARTMENT OF AGRICULTURE • FOOD SAFETY DIVISION
19 MARTIN LUTHER KING JR DRIVE SW • ATLANTA, GA 30334
ESTABLISHMENT INFORMATION
WATER
NAME (Doing Business As)
SOURCE:
DISPOSAL:
Public
Public
(Municipal)
(Sewer)
CORPORATE NAME (If registered with the Secretary of State’s Office)
COUNTY OF RESIDENCE
Private
Private
(Well)
(Septic System)
STREET ADDRESS
CITY
STATE
ZIP
GA
RIGHT OF ENTRY
MAILING ADDRESS (If Different)
CITY
STATE
ZIP
GA
Pursuant to O.C.G.A. § 26-2-36(a), the Georgia
Department of Agriculture is authorized to have free
OWNER INFORMATION
access during all hours of operation and at all other
NAME
TITLE
reasonable hours to any establishment where food is
manufactured, processed, packed or held for introduction
PHONE
EMAIL ADDRESS
into commerce.
By completing this application, I understand the foregoing
TYPE OF OWNERSHIP
comprising the legal
ATTACH A LIST OF OWNERS AND OFFICERS
(Individual, Corporation, Partnership, Association, etc.)
ownership, including any Registered Agents, with the
and hereby grant the Department right of entry to the
following information:
residence, during the normal business hours, or at other
Names / Titles / Addresses / Phone Numbers
reasonable times, for the investigation of consumer
complaints, foodborne disease outbreaks, or other public
PREREQUISITES
health emergencies.
Indicate your
and
of these requirements by checking the following:
ACKNOWLEDGEMENT
COMPLETION
I understand that inspections due to consumer complaints
I have checked with my city and county governments, and there are no local ordinances that would
or foodborne illnesses investigations are required to be
prevent me from operating a home-based business.
conducted within one hour upon receiving notice of the
intent to conduct an investigation. I further understand that
I have checked with my local public utilities to ensure that my cottage food operations meet their
refusing entry of a Department representative, and any
approval for the existing sewage system, or I have checked with the local health department to ensure
my septic system is adequate for my intended operations.
additional investigators with appropriate credentials who
may accompany the Department for the purposes of
I have attached either a copy of my most recent water bill, or the lab results where I had my private
investigating consumer complaints or foodborne illnesses,
well tested for coliforms and nitrates.
shall be grounds for revocation of my Cottage Food
I have completed an accredited food safety training course, and a copy of my certificate is attached to
License.
this License Application.
COTTAGE FOOD OPERATOR RESPONSIBILITIES
VERIFICATION OF LAWFUL PRESENCE
Please initial by each statement acknowledging the
.
OPERATOR
S RESPONSIBILITIES
A
Notarized Affidavit
and acceptable documentation are
required by O.C.G.A. § 50-36-1.
• I have read and understand the Food Safety Directives contained in the Cottage Food
Regulations 40-7-19-.08.
Please notify us if you have previously submitted an
affidavit and one acceptable document for any other
INITIALS
license or GATE card issues by the Department.
• I understand that I can only make the Cottage Food Products listed on this application
This will allow us to search our databases and upload
form, and that the sales of these products can only be to the end consumer.
the required documentation for your new license and
enable a better customer service experience.
INITIALS
• I understand that I can only sell these products within the state of Georgia, and that I cannot
For assistance, call the Customer Service Center at:
ship my products across state lines without having first obtained a Food Sales
855-4-AG-LICENSE (855-424-5423)
Establishment License from the Georgia Department of Agriculture and registering with
the FDA according to the Bioterrorism Act.
ATTESTATIONS
INITIALS
By signing this document, the applicant:
• I understand that if I sell my products by weight that I have to use a scale that is legal for
1.
Attests that the information provided on this form is
trade, and that it is my responsibility to contact the Georgia Department of Agriculture to
accurate; and
have my scale certified annually.
2.
Affirms he/she will comply with Department laws and
INITIALS
regulations related to the operation of a cottage food
establishment.
COTTAGE FOOD PRODUCTS LIST
**PLEASE DO NOT SUBMIT PAYMENT
Indicate each
you intend to produce:
WITH YOUR APPLICATION**
TYPE OF PRODUCT
You will receive an email link to pay your license fee approximately
Breads, Rolls & Biscuits
Cakes & Cupcakes
two (2) weeks following your licensing inspection.
Candies & Confections
Cereals, Trail Mixes & Granola
Questions? Please see our website at:
Coated / Uncoated Nuts
Dried Fruits
http://www.agr.georgia.gov/cottage-foods.aspx
Dry Herbs, Seasonings & Mixtures
Fruit Pies
Contact us via phone:
Jams, Jellies & Preserves
Pastries & Cookies
Food Safety Division: 404-656-3627, or
Popcorn, Popcorn Balls & Cotton Candy
Vinegars & Flavored Vinegars
Licensing Division: 404-586-1411
APPLICANT – PRINTED NAME
APPLICANT – SIGNATURE
APPLICANT – TITLE
DATE
SAVE
SUBMIT
PRINT