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STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Milk and Dairy Food Safety Branch
1220 N Street
Sacramento, CA 95814
(916) 900-5008
APPLICATION FOR A SEMI-FROZEN (SOFT SERVE) MILK PRODUCTS PLANT LICENSE
Application is hereby made for a license to operate a Semi-frozen (Soft Serve) Milk Products Plant for the
calendar year ending December 31, 2020 in ________________________ County.
NAME OF BUSINESS ___________________________________________ PHONE # _________________
(Include restaurant/store number if applicable)
LOCATION OF BUSINESS ___________________________________________________________________
Number Street Unit # City Zip Code
MAILING ADDRESS ________________________________________________________________________
Number Street City State Zip Code
CHECK ONE: Individual Partnership LLC Corporation FED TAX ID # _____ - ____________
NAME OF OWNER(S) (PLEASE PRINT; if corporation, give name of President):
LAST NAME: _________________________________________ FIRST NAME: ________________________
Signature: _______________________________________________________ Date: ___________________
PRODUCTS PROCESSED/MANUFACTURED:
Ice Cream Frozen Yogurt Nondairy Frozen Dessert
DATE TO BEGIN OPERATING:
MO DAY YEAR
If you begin operating: First Year’s Prorated License Fee:
Any Time between January 1 and March 31
$ 333.00
Any Time between April 1 and June 30
$ 249.75
Any Time between July 1 and September 30
$ 166.50
Any Time between October 1 and December 31
$ 83.25
Please make the check payable to: CDFA 90102 L and mail this application with the appropriate fee to:
CASHIER, California Department of Food and Agriculture
P.O. Box 942872, Sacramento, CA 94271-2872
Please be sure all information is COMPLETE & LEGIBLE. A license cannot be issued if application is incomplete.
**************************************************FOR CDFA USEONLY************************************************
New Plant: Yes No PREVIOUS OWNER’S LAST OPERATING DATE:
TYPE:
Regular Seasonal Mobile, Serial VIN Number: Plate #
The equipment and sanitary conditions at this facility are satisfactory for issuance of a Soft Serve License.
RDI’s Signature: RDI# _________ Date: ________
Amount Received $ RC#
Form 72-244/271 (rev.9/19)
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