MUP 2013-1062•
City of La Quinta
78-495 Calle Tampico
La Quinta, California 92253
PHONE: 760.777.7125 FAX: 760.777.1233
Office Use Only
Case Number Accepted Assigned 30 -Day
By To Deadline
/06 z
SE�
Notes:
MINOR USE PERMIT
APPLICATION
•
RECEIVED
SEP 04 2013
CITY OF LA QUINTA
COMMUWXQli OPMENT
Sections A, B and C are to be completed by the applicant in their entirety and shall be
accompanied by all listed plans, studies, reports and exhibits listed in Section Q unless
specifically waived by the appropriate City staff member and noted thereon.
SECTION A - PROJECT INFORMATION
Project Name
Project
Description:
APN #(s):
Site Address/
Location
General Plan
Specific Plan:
Proposed Phases:
OWIC
USC o it 1p"e )Q Tb k5Se-t-40l E o" Fct�o
/N( i�`kJM rNTU iArje�, 0 ,
Lout 4111,-7 Zoning:
r,J �A Proposed Use:
Related Cases:
I? L
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City of La Quinta - Planning Department - 760.777.7125 05.20.13
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SECTION B - STATEMENT OF OPERATIONS
The purpose of this form is to provide a detailed statement outlining the day-to-day operation of the
proposed project. Any approval related to this application will be based on the information provided
and will therefore. be subject to the continued operation of the proposed project consistent with the
information provided. Please be aware that any activities beyond those described here may result
in the need to amend your use permit in the future, thus it is encouraged that the information
provided be based on the ultimate operation level of the proposed use.
Description of proposed use: USE OE HoHE Lm7 t —] 'TD FILL /, t r4
Hours of operation: htlWft�IS i_-MVJ-SDVS 12,E – 2 pM
Number of employees:
J_
List any other local, .state or federal licenses or permits required: AHEHao( /nmw"
Types of equipment and processes used: F) LLED I W'O I L�SE' 6F
SfiyV L% -ice STCO-A U 2C I)Tp\)CI'LS E TAg-S -
Describe any hazardous materials used, stored, or produced on-site: '1
Describe any other special characteristics specific to the proposed use: W(I-L
11Is Nv ti E P I�kN I
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SECTION C - APPLICANT/OWNER INFORMATION
Applicant: S
W
(Name) (Phone)
(o D S SAS I"11� Ul2 9�2� SI�'12K-A wii�,I �l E t2Dfu , N eT_
(Mailing Address) (Email)
Owner(s): 61 ET-�1-A !:j&Nb'L
(Name) (Phone)
Architect:
(Mailing Address)
(Email)
(Phone)
(Mailing Address) (Email)
(California State License #)
Applicant Certification
1 certify that I have read this application packet in its entirety and .understand 'the City's
submittal and review process and the requirements for this application. I further certify
that each application item submitted as part of this application is consistent with the
minimum required contents for that item as described in Section D of this application. I
understand and agree that if during the processing of the application, it is determined the
information does not strictly meet such standards or contains errors or omissions,
clarification and/or supplemental information may be required and the preparation of such
information may be considered, in the Planning Director's judgment, an unreasonable
delay and will result in a suspension of processing time limits in accordance with the
California Code of Regulations, Title 14, Section 15109.
Applicant's Signature: 9A_)GG1 Date:
Print Name: Sl -a -f 4 toot N oz-
Owner Certification
1 certify under the penalty of the laws of the State of California that I am the property owner
of the property that is the subject matter of this application and I am authorizing and
hereby do consent to the filing of -this application and acknowledge that the final approval
by the City of La Quinta, if any, may result in restrictions, limitations and construction
obligations being imposed on this real property.
Owner/Authorized Agent Signature*: Gi(/ �►/�-�-- Date:'7�=
Print Name(s): SIUV4ZA I MNOL
"An authorized agent for the owner must attach a notarized letter of authorization from the legal property
owner. Any off-site work identified on the plans must be accompanied by a statement of authorization with a
notarized signature of the subject property owner.
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SECTION D - APPLICATION SUBMITTAL REQUIREMENTS
.APPLICATION SUBMITTAL REQUIREMENTS — INITIAL
TO BE COMPLETED BY CITY STAFF
Each of the following items is required for submittal
-a
unless a waiver is granted by City Staff. Any waiver
# of E -
°i
must be confirmed by initialing of this ;form by the
# of
copies
Waiver
>
person granting the waiver prior to submittal.. Please see
paper
in PDF
OK'd b y
Section D for the description and completion_
copies
format
(on CD-
(initials)
U)
requirements of each item.
ROM )
FS = Full Size / R = Reduced to 11 "x f 7"
FILING FEES
p
p
Filing Fees Receipt
1
NA
NA
APPLICATION INFORMATION
p
p
Application w/Statement of Operations
1
1
NA
E]
p
Site Photographs
1
1
PLAN SET
p
p
Index Sheet
1Fs/3R
1
.0
p
Site Plan
1 Fs/3R
1
NA
E]
p
Floor Plan
1 Fs/3R
1
Additional information may be required based on review of the project description.
Submittal waivers may be obtained through staff consultation, a pre -submittal meeting, or a
preliminary _review application. No applications will be accepted by mail.
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SUBMITTAL REQUIREMENTS - PRIOR TO HEARING
The following items sire to be submitted after
# E-
the project is schedulefor Planning
d'
# of
copies in
PDF
Submitted
Commission review and must be received by
paper
format
the Planning Department at least 12 working
copies
(on CD -
days prior to the scheduled PC meeting date.
ROM)
p
CEQA Filing Fees
1
NA
Bound 11"x17" reduction of complete final Plan Set with
3
1
colored Site Plan Sheets
Full size (not to exceed 24"06") complete final Plan Set
1
NA
with colored Site Plan Sheets
*If these required items are. not received by the Planning Department by the end of the day 12
working days before the scheduled PC meeting date, the project's review will be re -scheduled for a
later date.
SECTION E - SUBMITTAL ITEM DESCRIPTIONS
FILING FEES
Filing Fees -are to be paid at the .time of application. As part of the submittal process you will be
asked to pay your fees at the Finance Department counter and return to the Planning Department
counter with the receipt showing payment of fees which will be copied and submitted along with
the other application materials. Additional environmental review related fees (if any) will be
determined and payable at the time the application is determined complete.
REQUIRED AT TIME OF APPLICATION SUBMITTAL
Minor Use Permit Application Fee: $200*
REQUIRED AT TIME APPLICATION IS READY FOR FINAL REVIEW AND APPROVAL
CEQA Filing Fee: $64** Required regardless of exempt status
* Payable to City of La Quinta
* * Separate cashiers check payable to County of Riverside
APPLICATION INFORMATION
Application: A City application. form complete with all requested information and original
signatures in Sections A, B and C provided.
If you have any questions regarding filling out the Application, please contact the Planning
Department at (760) 777-7125.
Statement of Operations: The statement of operations portion (Section B) of the application
describing various operational aspects of the proposed use shall be completed.
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• •.
Site Photographs: Provide one aerial view, at least one panoramic view of each side of the site,
and specific views of any relevant or.unusual features. -of the site. Printed images shall be at least
4"W' and printed in color on 8'/2"x11" sheets.
If you have any questions regarding the Site Photographs requirement, please contact the
Planning Department at (760) 777-7125.
PLAN SET
Plan Set: A complete Plan Set shall contain one copy of each required.sheet, map or plan in the
order listed below, stapled together in the order prescribed as a comprehensive set, and folded so
that the folded size does not exceed 9"x12", rolled plans will, not be accepted. All
maps/plans/sheets shall be drawn on uniform sheets no greater than 24"x36" (or as approved by
the Planning Department prior to initial submittal). Each sheet shall .be drawn clear and legible, be
accurately scaled, fully dimensioned, drawn at the same scale unless otherwise instructed, and
include all the information as described in this section for each particular item.
Order of Plan Set Contents
1. Index Sheet
2. Site Plan
3. Floor Plan
1. Index Sheet The Index Sheet is the Plan Set's cover sheet and shall contain the following
information:
• Title block located in the lower right-hand corner of the map which contains the following
information and is readily visible when folded:
o Name of project
o Plan sheet identification number (such as 11 for Index, Sheet 1)
o Initial date of drawing and any subsequent revisions
o Name, address, and telephone number of person preparing map
o Name, address, and telephone number of owner, applicant, and/or agent
• A data table formatted in the following order:
o Assessors Parcel Number(s) (book, page and parcel number)
o Legal description
o Existing General Plan designation (and proposed if applicable)
o Existing Zoning designation (and proposed if applicable)
o Existing Specific Plan title and land use designation (and proposed if applicable)
o Existing land use and proposed land use
o Total net site area identified in square feet and acres
o Total building area identified in square feet and percentage of net site area
o Total parking area identified in both square feet and percentage of net site area
o Identification of parking ratios required by City code and provided
o Number of parking spaces required by City code and provided
o Number of Americans with Disabilities Act (ADA) parking .spaces required '& provided
o Occupancy classification (per California Building Code)
o Type of construction (per California Building Code)
• List of Plan Set sheets
• Vicinity map identifying project boundary line and location within surrounding neighborhood.
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If you have any questions regarding the above listed Index Sheet requirements, please contact
the Planning Department at (760) 777-7125.
2. Site Plan The Site Plan shall be prepared by a, qualified professional as stipulated by the
California Business and Professions Code and shall include the following information:
• Title block located in the lower right-hand corner of the map which contains the following
'information and is readily visible when folded:
o Name of project
o Plan name and sheet identification number (such as S1 for Site Plan Sheet 1)
o Initial date of drawing and any subsequent revisions
o Name, address, telephone number, signature and credentials stamp and license
number of the person preparing map.
o Name, address, and telephone number of owner, applicant, and/or agent.
• Graphic scale (engineering scale not to exceed 1" = 40')
• North arrow (typically with North facing,the top of the drawing)
• Location and dimension of all:
o property lines
o required and actual setbacks for building to property lines and buildings to buildings
o structures
o landscape areas
o drive aisles, parking stalls, and loading areas
o pedestrian pathways, including ADA horizontal path of travel
o trash enclosures
o storage areas
0 on-site fuel tanks (above or below ground)
o freestanding signs
o fire hydrants onsite and within 500' of the project site
o walls and fences
o public utilities
o public improvements, include cross sections
o structures, driveways, parking areas, trees and property lines within 50' of project
site's perimeter boundary
• Name, location and dimension of all adjacent public streets and ROWs
• Type, height, and location of all street, parking and pedestrian lights
• Identification of General Plan and Zoning land use designations and existing land use of
project site and all adjacent properties
• Identify interior and exterior turning radius dimensions at entries and drive aisles for
emergency vehicle access
• If the project includes any .phasing of development the proposed phases, including public
improvements, shall be identified on a separate site plan sheet with a table showing acreage,
building square footage, number and type of units, and number of parking spaces per phase.
If you have any questions regarding the above listed Site Plan requirements, please contact the
Planning Department at (760) 777-7125.
3. Floor Plan The Floor Plan shall be prepared by a qualified professional as stipulated by the
California Business and Professions Code and shall include the following information:
• Title block located in the lower right-hand corner of the map which contains the following
information and is readily visible when folded:
o Name of project.
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o Plan name and sheet identification number (such as F1 for Floor Plan Sheet 1)
o Initial date of drawing and any subsequent revisions
o Name, address, telephone number, signature and credentials stamp and license
number of person preparing map.
o Name, address, and telephone number of owner, applicant, and/or agent
o California License Stamp
• Graphic scale (not smaller than the %"=1')
• North arrow (typically with North facing the top of the drawing)
• Allocation and use of all interior and exterior space, including areas for waiting, gathering,
eating, storage or display of merchandise
• Location of all walls, doors, and window openings
If you have any questions regarding the above listed Floor Plan requirements, please contact the
Planning Department of (760) 777-7125.
REQUIREMENTS TO BE SUBMITTED PRIOR TO APPROVAL
CEQA Filing Fees: Checks payable to County of Riverside in the amounts specified for the
proposed Environmental Determination as identified by the Planning. Department
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PREPARED 9/04/13, 9:47:21 PAYMENTS DUE INVOICE
CITY OF LA QUINTA PROGRAM PZ821L
---------------------------------------------------------------------------
PROJECT NUMBER: 13-00000171 MUP 2013-1062 - CFO FOR DRY FOOD PACKAGI
FEE DESCRIPTION AMOUNT DUE
---------------------------------------------------------------------------
MUP (F) 200.00
TOTAL DUE 200.00
Please present this invoice to the cashier with full payment.
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PREPARED 9/04/13, 9:47:21 PAYMENTS DUE INVOICE
CITY OF LA QUINTA PROGRAM PZ821L
---------------------------------------------------------------------------
PROJECT NUMBER: 13-00000171 MUP 2013-1062 - CFO FOR DRY FOOD PACKAGI
FEE DESCRIPTION AMOUNT DUE
---------------------------------------------------------------------------
MUP (F) 200.00
TOTAL DUE 200.00
Please present this invoice to the cashier with full payment.
•
• -tt 4"4A
C(� fl q/ 4a C4)
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
September 16, 2013
Ms. Sierra Wagner ILL
78605 Sanitar
Drive
La Quinta, CA 92253
SUBJECT: MINOR USE PERMIT 2013-1062
COTTAGE FOOD OPERATION AT 78605 Sanita Drive
Dear Ms. Wagner:
(760) 777-7000
FAX (760) 777-7101
The Community Development Department has reviewed your request for a Cottage
Food Operation in your residence at 78605 Sanita Drive. This letter is to notify
you that your request has been approved and is subject to the following Conditions
of Approval:
1 . The cottage food operation shall be registered o- permitted as a "Class A" or
"Class B" operation by the Riverside County Department of Environmental
Health, in accordance with Riverside County Ordinance 916 and Section
114365 of the California Health and Safety Code. Evidence of said
registration or permit issuance by the County shall be provided to the
Community Development Department prior to issuance of a City of La Quinta
business license. All cottage food operations require a City of La Quinta
business license to be procured subsequent to, and in compliance with,
approval of the minor use permit application and associated conditions of
approval.
2. The cottage food operation shall be clearly incidental to the use of the
structure as a dwelling unit, and shall not create dust, noise or odors in
excess of that normally associated with residential use.
3. The cottage food operation shall not generate pedestrian or vehicular traffic
in excess of that normally associated with residential use.
4. No direct sales or service from the residence or property on which the
residence is located is permitted. The cottage food operation shall not be the
point of customer pickup or delivery of products or services, nor shall a
cottage food operation create greater vehicular or pedestrian traffic than
normal for the residential zoning district in which it is located.
5. The cottage food operation shall be conducted solely within the primary
residence.
6. Sign(s) identifying the cottage food operation are not permitted to be posted
or displayed on the premises, nor on or within anything located on the
premises, except as may be required by any federal, state, and/or local
permitting agency. Neither the dwelling nor the property shall be altered to
appear other than a residence, either by color, materials, construction,
lighting, sounds, vibrations or other characteristics.
7. No more than one (1) cottage food employee, as defined by California Health
and Safety Code Section 113758(b)(1), shall -be employed by the cottage
food operation, not including any residing family or household member.
This minor use permit may be revoked for any violation of LQMC Section .9.60.1 15
or of Section 114365 et seq. of the California Health and Safety Code. The city
may, for inspection purposes, access the permitted area of a private home where a
cottage food operation is located if the city has, on the basis of any complaint(s),
reason to suspect that the cottage food operation has violated the provisions of
this Section and/or California Health and Safety Code Section 114365 et seq.
Furthermore, the City may also conduct routine periodic inspections to ensure
compliance with the provisions and conditions of the cottage food operation's
minor use permit 'an.d City business license.
This approval is final, but may be appealed by anyone to the Planning Commission
provided the required forms and filing fee of $1,573.00 are filed with this office
within fifteen (15) days of the date of this letter.
Should you have any questions, please call me at (760) 777-7125.
Sincerely,
WALLACE NESBIT
Principal Planner
c: Riverside County Fire Department
Code Compliance Division
e
COUNTY OF RIVERSIbE
DEPARTMENT MJF ENVIRONMENTAL HEALTH
e
CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)
COTTAGE FOOD OPERATION (CFO)
REGISTRATION / PERMITTING FORM
CFO Business Name:
THE GIFTED COOKIE
CFO Physical Address:
78605 SANITA DR.
Owner Name:
SIERRA WAGNER
Mailing Address (if different):
Email Address:
GIFTEDCOOKIE@GMAIL.CO
M
Website:
THEGIFTEDCOOKIE.COM
1. Categories:
CFO City:
LA QUINTA
Owner Phone:
(714) 791-6290
Mailing City:
CFO ZIP:
92253
Owner Cell:
(714)791-6290
Mailing ZIP:
X Class A" (Direct Sales Only) "Class B" ( Direct & Indirect Sales)
$145/year $290/year
2. Prohibited Items: Initial if you agree to abide by the following:
Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT
ALLOWED. Only foods that are defined as "non -potentially hazardous" are approved for
preparation by a Cottage Food Operation (CFO). These are food items that do not require
refrigeration to keep them safe from bacterial growth that could be a cause of food -borne
illness.
3. "Class A" Self Certification Checklist:
Checklist completed ("Class A" CFOs Only)
X
Rev 1/2013
Page 1 of 6
4. Products:
Please check ALL of the items you will be preparing and/or selling.
Baked Goods x Dried Pasta
Candy X Dry Baking Mixes
Churros Waffle Cones
Dried Mole Paste X Herb/Spice Blends
x Trail Mix Fruit Tamales/Pies
Fruit Empanadas Nut Butters
Sweet Sorghum
Syrup
Other:
"These
items must
comply
with
standards
described
in Part
150 of
Title 21 of
the Code
of Federal
Regulation
s
http://www
.accessdat
a.fda.gov/
scripts/cdr
h/cfdocs/cf
CFR/CFR
Search.cf
M?
CFRPart=
150
x Granola/Cereals
Honey
Mustard
Tortillas
Pizelles
Nuts/Nut
Mixes
x Dried Tea
Chocolate
X Covered
Nonperishab
le Food
Popcorn
Vinegar
Fruit Butter **
Jams/Jellies**
x Dried Fruit
x Roasted Coffee
Food descriptions:
LAYERED DRY COOKIE MIXES IN A SEALED JAR, DRY SAVORY MIXES IN A JAR.
5. Product Labeling: Initial if you agree to abide by the following:
For a detailed description, see the CDPH document "Labeling Requirements for Cottage
Food Products." All cottage food products must be properly labeled in compliance with
Rev 1/2013
Page 2 of 6
the Federal, Food, Drug, and Cosmetic Act (21 U.S.C. Sec. 343 et seq.) The label must
include:
G The words "Made in a Home Kitchen" in 12 -point type.
G The name commonly used to describe the food product.
G The CFO business name, city, state and zip code of the cottage food operation
which produced the cottage food product. If the firm is not listed in the current
telephone directory then a street address must also be declared. (A contact phone
number or email address is optional but may be helpful for consumers to contact
your business.
G The registration or permit number of the cottage food operation which produced
the cottage food product and in the case of "Class B" CFOs; the name of the county,
where the permit was issued.
G The ingredients of the food product, in descending order of predominance by
weight, if the product contains two or more ingredients.
G The net quantity (count, weight, or volume) of the food product. It must be stated
in both English. (pound) units and metric units (grams).
ig A declaration on the label in plain language if the food contains any of the eight
major food allergens such as milk, eggs, fish, shellfish, tree nuts, wheat, peanuts,
and soybeans. There are two approved methods prescribed by federal law for
declaring the food sources of allergens in packaged foods: 1) in a separate or
statement immediately following or adjacent to the ingredient list, or 2) within the
ingredient list.
G If the label makes approved nutrient content claims or health claims, the label
must contain a "Nutrition Facts" statement on the information panel.
o The use of the following eleven terms are considered nutrient content
claims (nutritional value of a food): free, low, reduced, fewer, high, less, more,
lean, extra lean, good source, and light. Speck requirements have been
established for the use of these terms. Please refer to the Cottage Food
Labeling Guideline for more details.
o A health claim is a statement or message on the label that describes the
relationship between a food component and a disease or health-related
condition (e.g., sodium and hypertension, calcium and osteoporosis). Please
refer to the Cottage Food Labeling Guideline for more details.
G Labels must be legible and in English (accurately translated information in
another language may accompany it).
G Labels, wrappers, inks, adhesives, paper, and packaging materials that come
into contact with the cottage food product by touching the product or penetrating the
packaging must be food -grade (safe for food contact) and not contaminate the food.
G Sample of label must be submitted prior to final approval.
Example:
Rev 1/2013
Page 3 of 6
•
w v 6.. ...0 �+ � Pu..• r`�se
b) within the ingredient list.
See an example of a cottage food label below (principal display panel):
MADE it A HOME KFTCHEN
Permit p: 12315
Issued to county: County name
Clwcolate Chip Cookies R7th walla its
&,Ily- Baker
23 Cottage Food Lane
Anylsi cre. CA 90XXX
Ingredients: Enriched flour (Vklww flour. uinca< reduced imu thiamine.
morwrumte. nboflmi and folic acid). butter (milk, sall), chocolate chips
(sugar, chocok,te litpun. eacon butler. btmedm (milk). unlam. arear. cup.
salt artificial a,;miWt extract, baking sods.
Contains: Wheal. eggs, utilk, soy, malnuts
Net %M. 3 oz (85.0199)
St�
(8) The use of the following eleven terms are considered nutrient content claims (nutritional I
o..a
'yam eTrJ
•
6. Water Source:
Please identify the water source to be used in Cottage Food Facility (Check one box)
Name of Public Water System or Community Services District: COACHELLA VALLEY
WATER DISTRICT
If you use a Private Water Supply*, identify the source (well, spring, surface, etc.):
Private Water Su p-ty. Initial Water Quality Results
Check boxes below if initial water testing has been completed.
All testing must be done at a State Certified Laboratory.
Attach a copy of the lab results and list the results in the space provided next to type of
test.
Bacteriological Test (quarterly):
Nitrate Test (yearly):
Arsenic (yearly, if applicable':
Fluoride (once):
*Additional information may be required if food is prepared from a home with a private water supply — Check with our Department.
7. Disposal of Waste:
Please check what type of treatment is used to dispose of waste
X Public Sewer Service Private Septic System
In the event of septic system failure or plumbing problem, you are required to notify
Riverside County Department of Environmental Health immediately and discontinue all
cottage food operations until repairs are completed.
Rev 1/2013
Page 4 of 6
8. Food Processor Course: Initial if you agree to abide by the following:
Within 3 months of being approved to operate by the Environmental Health
Department, please provide proof of completion of the required California Department of
Public Health (CDPH) food processor course*. Proof of completion may be faxed to our
Department at (951)-358-5017.
* See CDPH Website for more information: http://www.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx
9. Employee: Initial if you agree to abide by the following: Svc
I understand that I may not have more than one full-time equivalent cottage food
employee, not including a family member or household member of the cottage food
operator, working within the registered or permitted area of a private home where the
cottage food operator resides and where cottage food products are prepared or
packaged for direct, indirect, or direct and indirect sale to consumers.
10. Gross Annual Sales: Initial if you agree to abide by the following: '5J
I understand that I will lose my CFO status and will need to become permitted in a
commercial facility if my CFO business exceeds the following gross annual sales figures
for the calendar years in the following table:
Calendar Year Gross Annual Sales
In 2013............................................................$35,000
In 2014............................................................$45,000
In 2015 and in subsequent years...................$50,000
11. Delivery Limitations: Initial if you agree to abide by the following:
I understand that I may accept orders and payments via the internet, mail or phone.
However, all "Class A" & "Class B" CFO products must be delivered directly (in person) to
the customer. The CFO products may not be delivered via US Mail, UPS, FedEx or using
any other indirect delivery method as this is regulated/subject to CDPH registration and
state and federal requirements.
12. Zorling Requirements: Initial if you agree to abide by the following:
I understand that I must comply with all applicable zoning requirements for the
jurisdiction in which I live.
I have attached documentation from the Planning office (if required)
13. Owner's Statement:
Rev 1/2013
Page 5 of 6
I, SjEUA- wA,-6NLYL . agree to grant access to the local health department
to conduct an inspection of my cottage food operation (mark one):
X "Class A": In the event of a
consumer complaint or reported
food -borne illness
"Class B": For regular annual facility
inspections and in the event of a
consumer complaint or food -borne
illness
I,-51cv-AA- W&jNM , agree to notify Riverside County Department of
Environmental Health prior to modifying my food list, type of operation, and/or method of
selling, distributing, or otherwise providing my CFO products to the consumer or
retailers, regardless of whether the product is sold, consigned, or given away.
Owner's Signature Print Name Date
DRIVER'S LICENSE #
EHS/OFFICE USE ONLY
EXPIRATION DATE
SAMPLE LABEL RECD BY (INITIALS OF EHS)
COPY OF PLANNING APPROVAL RECD BY (INITIALS OF EHS)
ONSITE OF CFO INPECTION COMPLETED ON
APPROVED BYEHS:
AMT RECD
DATE OF PAYMENT
(SIGNATURE)
DATE RECD
BY
(DATE)
PAYMENT TYPE: (1) CASH (2) CHECK (3) CREDIT/DEBIT
CHECK# DATE OF CHECK INVOICE#
OWNER # FACILITY# PROGRAM REC #
Rev 1/2013
Page 6 of 6
(INITIALS OF EHS)
(DATE)
P EASE N : If the will be any tcn % tr �, nor elft cal connections., please
ha, the client go'to ih 'dig Dep eirt FDZ STtc (determine
/ i a Building ermit is re red before acc
empomy or Tae Permit.
Client: ease be a ' id the c-ommunit, evelopment.I3E ent -will cnW
you to let ou know if -Your OVIO letter, o be picked in the
Co Development wilding De ents.
r Binding Def+a ; t Use a7ji
1 P'ennit required: o No..M
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