Fill - Free fillable REQUIREMENTS FOR COMPLETING THE APPLICATION FOR CREMATORY LICENSE (California) PDF form

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

CEMETERY AND FUNERAL BUREAU

1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834

P 916.574.7870 F 916.928.7988 www.cfb.ca.gov

REQUIREMENTS FOR COMPLETING THE APPLICATION FOR CREMATORY LICENSE

To be considered complete, the application must include

1. Completed application with correct fees.

2. A corporate resolution delegating authority to submit the application, if applicant is a

corporation.

3. A certified copy of your Articles of Incorporation if applicant is a corporation (may be obtained

from the Secretary of State’s web site located at www.ss.ca.gov/business).

4. Partnership agreement, if applicant is a partnership.

5. Permit to operate a crematory issued by the local air pollution control district.

6. Land use or zoning permit.

7. Certified copy of a Deed, lease, or other instrument which provide the applicant with the right to

possess and use the property where the business will be located.

8. A statement signed by the applicant if the applicant is an individual; signed by the majority and

verified by one of the directors, if the applicant is a corporation; or signed and verified by a

majority of the partners, if applicant is a partnership, which statement shall set forth the

following three requirements:

A. A complete and detailed financial statement showing assets, liabilities and reserve.

B. A statement of proposed plan of operation which shall include the type of selling. The

statement should include what they sell and to whom (i.e. merchandise, cremation

services available to the public, etc.) and a copy of any price lists for goods and

services if they sell to the public. If services are not available to the public, then the

statement should indicate that.

C. A full, true, and complete copy of the standard agreement which will be used for

funding of prearranged cremations.

9. Plans and specifications of the crematory and building, which must be sufficient to allow the

Bureau to determine, among other things, adequacy of storage for cremated and non-cremated

remains.

10. Copy of a recent fire inspection report or a certificate of occupancy.

11. Evidence of a written contract with a licensed cemetery for final disposition of cremated remains

that are in its possession after 90 days of the date of death.

12. Submit Certification Affidavits for all officers, owners and partners.

If you have any questions or need clarification about any of the documents that need to be submitted

to complete the Crematory application, please contact the Cemetery and Funeral Bureau Licensing

Unit.

REV (07/20) Cemetery and Funeral Bureau – www.cfb.ca.gov Page 1 of 4

APPLICATION FOR CREMATORY LICENSE

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

CEMETERY AND FUNERAL BUREAU

1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834

P 916.574.7870 F 916.928.7988 www.cfb.ca.gov

INITIAL FILING FEE $400.00

CR NUMBER ISSUED

SECTION A: CREMATORY INFORMATION

Name of Crematory If this is an existing Crematory, current

CR Number

Address of Crematory City State

Zip Code

Mailing Address of Crematory

(If different from above) City State Zip Code

Phone Number

( )

Fax Number

( )

Email Address (Not required)

FEIN Number Date of Sale (If applicable)

SECTION B: NAME OF PERSON FILING THE APPLICATION

(If corporation, submit copy of a resolution delegating authority to applicant to submit the application.)

Last First Phone Number (If different than above)

( )

SECTION C: NAME OF DESIGNATED CREMATORY MANAGER

Last First License Number

CRM

Expiration Date

SECTION D: APPROVAL TO SHARE CREMATORY MANAGER

(If applicable, must be under common ownership and within 60 miles of the main office)

Name of Crematory Designated as Main Office License Number

Miles From New

Crematory

List CR Numbers of Additional

Crematories Managed

CR Number CR Number CR Number CR Number CR Number CR Number

SECTION E: OWNERSHIP

If owner is an INDIVIDUAL, complete the following:

Last Name First Middle Initial

ATTACH A COMPLETED CERTIFICATION AFFIDAVIT.

If owner is a PARTNERSHIP, list ALL partners and percentage owed:

(Attach additional pages if needed)

Last Name First Middle Initial % Owned

ATTACH A COMPLETED CERTIFICATION AFFIDAVIT FOR EACH PARTNER.

FOR BUREAU USE ONLY

Date Cashiered Amount Cashiered ATS Number Receipt Number

Completed On

REV (07/20) Cemetery and Funeral Bureau – www.cfb.ca.gov Page 2 of 4

If owner is a CORPORATION, complete the following

Name and address of Corporation (Exact name and address as shown on Articles of Incorporation)

Incorporated in State of Date Incorporated

CORPORATE OFFICERS – List top 4 senior officers of the corporation.

Title Last Name First Middle Initial

President

Vice President

Treasurer

Secretary

ATTACH A COMPLETED CERTIFICATION AFFIDAVIT FOR EACH OFFICER.

SECTION F: APPLICANT CERTIFICATION

I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this

application are true and accurate.

Signature Title Date

Note: The information solicited on this form is required pursuant to Business and Professions Code Section 9781. All items in this application are

mandatory; none are voluntary, unless indicated. Failure to provide any of the requested information will result in the application being considered

incomplete (incomplete applications are subject to abandonment one year from the date the applicant is notified of deficiencies). All information provided

will be used to determine qualification for licensure, per the Business and Professions Code that authorizes the collection of this information. Per

California Civil Code Section 1798.17 (Information Practice Act), the Chief of the Cemetery and Funeral Bureau is responsible for maintaining information

in this application. This information may be transferred to other governmental and enforcement agencies. Individuals have the right to review the records

maintained on them by the agencies, unless the records are exempt by Section 1798.40 of the Civil Code. Requests for information may be addressed to the

custodian of records: Bureau Chief, Cemetery and Funeral Bureau, 1625 North Market Blvd., Suite S208, Sacramento, CA 95834 (916) 574-7870.

REV (07/20) Cemetery and Funeral Bureau – www.cfb.ca.gov Page 3 of 4

I am completing this Affidavit as a:

Sole Owner

Partner Officer Trustee

Name of Funeral Establishment, Cemetery, Crematory or Corporation this affidavit is being submitted on behalf of

Phone Number License Number of FD, CR or COA (If applicable)

( )

Last Name First Middle

Initial

Address City State Zip Code

Date of Birth Social Security Number Title (If applicable)

Have you previously submitted fingerprint cards or a copy of a Request for Live Scan Service Form

to the Cemtery and Funeral Bureau?

If yes, for what license, and the approximate date. _____________

Yes

________________________

If no, submit a copy of your completed Request for Live Scan Service form, along with this application, verifying that

fingerprints have been scanned and all applicable fees have been paid.

Have you ever had any professional or vocational license or registration denied, suspended, revoked, placed on probation or

other disciplinary action taken by this or any other governmental authority in this state or any other state, or any foreign

country

Yes No

If "yes," please attach an explanation that includes license type, action, and company name

(if applicable), year of action and state.

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

CEMETERY AND FUNERAL BUREAU

1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834

P 916.574.7870 F 916.928.7988 www.cfb.ca.gov

CERTIFICATION AFFIDAVIT

To be completed by each Owner, Partner, Officer, and Trustee (Make additional copies as needed).

I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and

representations made in the foregoing certification affidavit, including all supplementary statements.

Signature Date

FOR BUREAU USE ONLY

Fingerprints on File with Live Scan Results Received on

Approved by Enforcement Approval Date

REV (07/20) Cemetery and Funeral Bureau – www.cfb.ca.gov Page 4 of 4

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

CEMETERY AND FUNERAL BUREAU

1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834

P 916.574.7870 F 916.928.7988 www.cfb.ca.gov

NOTICE ON COLLECTION OF PERSONAL INFORMATION

Collection and Use of Personal Information

The Cemetery and Funeral Bureau of the Department of Consumer Affairs collects the

personal information requested on this form as authorized by Business and Professions

Code Sections 30, 144, 7617.1, 7618, 7619, 7620, 7628, 7642, 7643, 7661, 7662, 7665,

7667, 9650, 9650.2, 9650.3, 9700, 9701, 9702.1, 9704, 9715, 9715.1, 9716, 9723,

9723.1, 9741, 9745, 9746, 9781, 9787.3 and the Information Practices Act. The

Cemetery and Funeral Bureau uses this information principally to identify and evaluate

applicants for licensure, issue and renew licenses, and enforce licensing standards set by

law and regulation.

Mandatory Submission

Submission of the requested information is mandatory unless otherwise noted on the

form. The Cemetery and Funeral Bureau cannot consider your application for licensure or

renewal unless you provide all of the requested information.

Access to Personal Information

You may review the records maintained by the Cemetery and Funeral Bureau that

contain your personal information, as permitted by the Information Practices Act. See

below for contact information.

Possible Disclosure of Personal Information

We make every effort to protect the personal information you provide us. The information

you provide, however, may be disclosed in the following circumstances:

 In response to a Public Records Act request (Government Code Section 6250 and

following), as allowed by the Information Practices Act (Civil Code Section 1798 and

following);

 To another government agency as required by State or Federal law; or,

 In response to a court or administrative order, a subpoena, or a search warrant.

Contact Information

For questions about this notice or access to your records, you may contact the Custodian

of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,

Sacramento, CA 95834, by phone at (916) 574-7870, or by e-mail at

emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may

contact the Department of Consumer Affairs at 1625 North Market Boulevard,

Sacramento, CA 95834, by phone at (800) 952-5210, or by e-mail at dca@dca.ca.gov.

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