Form Cdph 8591 – Fill Out and Use This PDF

State of California—Health and Human Services Agency	California Department of Public Health
	Food and Drug Branch

COLD STORAGE OR REFRIGERATION FACILITY LICENSE APPLICATION

PLEASE COMPLETE THIS FORM FULLY—INCOMPLETE APPLICATIONS WILL BE RETURNED

See Page 2 for Instructions.

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)
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

21.	Owner’s Name / Corporate Name (if applicable)	State of Incorporation
22.	Owners’ or Officers’ Names and Titles	Owners’ or Officers’ Names and Titles

By signature, I declare under penalty of perjury that all information provided herein is true and correct.

PLEASE DO NOT WRITE BELOW THIS LINE

Cold Storage or Refrigeration Facility 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 Cold Storage or Refrigeration Facility 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 Cold Storage or Refrigeration Facility License for this location and you are renewing that license. 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.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 and Titles: List the business owners’ or officers’ names and titles.

23.Other Valid Licenses or Registrations: Enter the license or registration name, license or registration number, and expiration date for each Department of Public Health license or registration that your firm has been issued.

24.Sign the application, enter date signed, and print your name and title.

**LICENSE FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE TO OTHER LOCATIONS OR ENTITIES

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	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.