Fillable HOME PROCESSOR REGISTRATION REQUEST (New York State)

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HOME PROCESSOR REGISTRATION REQUEST (New York State)

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The HOME PROCESSOR REGISTRATION REQUEST (New York State) form is 1 page long and contains:

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  • 4 check-boxes
  • 22 other fields

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File type: PDF

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FSI-898c (Rev. 03/20)
NYS Department of Agriculture and Markets
Division of Food Safety and Inspection
HOME PROCESSOR REGISTRATION REQUEST
Date
Owner Name
County
Trade Name
Street Address
City
Zip Code
Phone Number
E-mail Address
LIST COMMON OR USUAL NAME (I.E. COOKIES, CAKES, ETC.) OF THE PRODUCTS THAT YOU
PROPOSE TO MANUFACTURE. IF NECESSARY, INCLUDE A BRIEF DESCRIPTION OF THE PRODUCT.
1. _______________________________________ 2. _____________________________________
3. _______________________________________ 4. _____________________________________
5. _______________________________________ 6. _____________________________________
7. _______________________________________ 8._____________________________________
9. _______________________________________ 10._____________________________________
*Products are subject to approval and approval must be obtained for any added products after initial registration
---------------------------------------------------------------------------------------------------------------------------------
Please check one
Water supply is a (public/municipal supply) (private well)*
*For private wells, attach a copy of the most recent acceptable water analysis (no more than three months old)*
---------------------------------------------------------------------------------------------------------------------------------
Product labels are required to contain the following information: common/usual name of the product,
ingredient list in predominance by weight, net quantity of contents, and processor name and full address.
I understand that my product labels must comply with the listed requirements. ______ (initial)
By signing this form, I acknowledge that I have read and understand the provisions of the 20C Exempt Home
Processing registration (https://agriculture.ny.gov/food-safety/home-processing). I agree to these provisions
and limitations of the exemption particularly as it concerns products that may be produced. I further understand
that violations of this agreement will result in revocation of my home processing registration and I may be
subject to civil penalties.
Signature of Home Processor
Date Reviewed:
Approved: Yes No
Reason not approved:
Reviewers Signature
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HOME PROCESSOR REGISTRATION REQUEST (New York State)

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Completed 18 May 2022

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