MUP 2013-1064City 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
Notes:
MINOR USE PERMIT
APPLICATION
•
'RECEIVED
t�
SEP 2 6 2013
CETY OF LA QUINTA
COMMUNITY DEVELOPMENT
Planning Stamp
D°
SEP 2 G 2013
CITY OF LA QUINTA
FINANCE DEPT.
Phancu Stamp
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 D unless
specifically waived by the appropriate City staff member and noted thereon.
SECTION A - PROJECT INFORMATION
Project Name
Project
Description:
Site Address/
Location: s i u-gc AA_P_viiac-,, (
Z Z. �3
General Plan:
Specific Plan:
Proposed Phases:
Zoning:
Proposed Use.-
Related
se:
Related Cases:
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• 1 •
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:t ( VV -CG 1Cs_ OCk & QGX S Qz CCG (� C^
Hours of operation: ) a w_ - I Z. G --W
Number of employees:
List any other local, state or federal licenses or permits required: rJ lii2f")1C�0 (����) liri..
Types of equipment and processes used: Ue /� Ut? _ WQ Gf_U U,)O VLQ
Describe any hazardous materials used, stored, or produced on-site:
Describe any other special characteristics specific to the proposed use:
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40hNER/AGEN5TSIGNATURE
DATE
AGENT COMPANY NAME CONTACT PH. # DATE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR DENYING
YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH THE CONDITIONS LISTED ON THE
ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF PERMIT.
********************************************************************************************
BUILDING AND SAFETY DEPARTNIENT/CODE COMPLIANCE DIVISION:
APPROVED DENIED SPECIAL CONDITIONS
OFFICER I.D. # DATE
U
SECTION C - APPLICANT/OWNER INFORMATION
Applicant:
Owner(s):
Architect:
•
(Name) \ (Phone)
O (�a -
(Mailing Address) (Email)
(Name) (Phone)
(Mailing Address) (Email)
(Name) (Phone)
(Mailing Address) (Email)
(California State License #)
Applicant Certification
l.cuyv?
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. 1
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 Regula ' ns, Title 14 Sectio 15109.
Applicant's Signature: TWo� Date: cA7&3
Print Name: �odac D --)(,-O h G
Owner Certification
I 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 / 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*:
Date:
Print Name(s):
*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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0
•
SECTION D - APPLICATION SUBMITTAL REQUIREMENTS
APPLICATION SUBMITTAL REQUIREMENTS - INITIAL
TO BE COMPLETED BY CITY STAFF
Each of the following items is required for submittal
# of E-
V
unless a waiver is granted by City Staff. Any waiver
d
must be confirmed by initialing of this form by the
# of
copies
in PDF
Waiver
'�
>_
person granting the waiver prior to submittal. Please see
paper
format
OK'd by
M
cc
Section' D for the description and completion
copies
(on CD-
(initials)
N
requirements of each hem.
ROM)
FS = Full Sire / R = Reduced to 11 "x 17"
FILING FEES
F0
I Filing Fees Receipt
1
NA
NA
APPLICATION INFORMATION
E
p
Application w/Statement of Operations
1
1
NA
p
Site Photographs
1
1
PLAN SET
❑
p
Index Sheet
1 Fs/3R
1
❑
p
Site Plan
1 Fs/3R
1
NA
El
❑
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 are to be submitted after
# of E -
the project is scheduled' for Planning
# 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)
❑
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 NNW) 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"x6" and printed in color on 8'/"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 Wx12", 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 anyquestions regarding the above listed Floor Plan requirements, please contact the
Planning Department at (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
Minor Use Permit Application Page s of s
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PREPARED 9/26/13, 8:23:39 PAYMENTS DUE INVOICE
CITY OF LA QUINTA PROGRAM PZ821L
---------------------------------------------------------------------------
PROJECT NUMBER: 13-00000185 MUP 13-1064 CANDACE GAUNA
FEE DESCRIPTION AMOUNT DUE
---------------------------------------------------------------------------
MUP (F) 200.00
TOTAL DUE 200.00
Please present this invoice to the cashier with full payment.
0
•
4�0 �u�fw
P.O. Boy: 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLS TAMPICO - (760) 777-7000
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
October 14, 2013
Ms. Candace Gauna FILE COPY
51680 Avenida Obregon
La Quinta, CA 92253
SUBJECT: MINOR USE PERMIT 2013-1064
COTTAGE FOOD OPERATION: TBC Cake Pops and Treats
Dear Ms. Wagner:
The Community Development Department has reviewed your request for a Cottage
Food Operation in the residence located at 51680 Avenida Obregon. This letter is
to notify you that your request has been approved and is subject to the following
Conditions of Approval:
The cottage food operation shall be registered or 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
ree istration or permit_ issuance by the County shall be provided to th_e
Communit
y Development Departmentprior 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 whichthe
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
�s
k;
i
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 9.60-115
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 and 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,
%Al/
WALLACE NESBIT
Principal Planner
c: Riverside County Fire Department
Code Compliance Division
r •
Monika Radeva
From: Garcia, Jacqueline@CALFIRE <Jacqueline.Garcia@fire.ca.gov>
Sent: Wednesday, October 23, 2013 4:52 PM
To: Planning WebMail
Subject: RE: Minor Use Permit 2013-1064
Riverside County Fire Department has no comments/conditions for Cottage Food Operation: TBC Cake Pops Treats.
JacqueCine Garcia
Fire Safety Specialist
Riverside County Fire Department
(760) 863-8886
(760) 427-9881 cell
(760)863-7072 fax
f/I I copy
COUNTY OF RIVERSIDE
�DEPA*MENT OF ENVIRO�ENTAL HEALTH
COTTAGE FOOD OPERATIONS (CFOs — Class A)
SELF CERTIFICATION CHECKLIST
The following requirements are outlined in the Cottage Food Operations (CFO) regulations and are provided as minimum standards
of health and safetyfor the preparation of approved cottage foods in the home.
CFO BUSINESS NAME: OWNER NAME:
I I l I� v- r -p(.+- s (s-rd0Lce ('?C,,U na
PHYSICAL ADDRESS: CITY: ZIP:
Auenocn%r,r, 2\610 Lj
Zz 3
FOR OFFICE USE
FA PR SR PE
Facility Requirements: Yes No
1. The CFO is located in a private dwelling where the CFO operator currently resides ❑
2. All CFO food preparation will take place in the private kitchen within that home. ❑
3. Additional storage used for the CFO will be within the home. ❑ (�
a. If YES, is the room used exclusively for storage? ❑ ❑
b. Specify the room(s) that will be used for storage?
4. Sleeping quarters are excluded from areas used for CFO food preparation or storage. ❑
Zoning Requirements: Yes No
5. I have complied with the applicable zoning requirements for the CFO. W ❑
6. I have attached documentation from the Planning office (If required) ❑ ❑
Employee and Training Requirements: Yes No
7. Have all persons preparing or packaging CFO products completed the CDPH food processor
course? ❑ X
a. If YES, copies of certificates are attached. ❑ ❑
b. If NO, complete course within 3 months of CFO registration and forward a copy to the El
Health Office where registration was completed.
8. The CFO has no more than 1 full-time equivalent employee? (Immediate family or household ❑
members are not included.) 91
Sanitation Requirements: Yes No
9. Kitchen equipment and utensils used to produce CFO products are clean and maintained in a 11good state of repair.
10. All food contact surfaces, equipment, and utensils used for the preparation, packaging, or ® 0
•
handling of any CFO products shall be washed, rinsed, and sanitized before each use.
11. All food preparation and food and equipment storage areas shall be maintained free of rodents
and insects.
Food Preparation Requirements, (includes packaging and handling):
12. Hand washing is required immediately prior to handling foods and after engaging in any
activity that contaminates the hands such as after using the toilet, coughing or sneezing, eating
or smoking.
13. Warm water, hand soap and clean towels are available for hand washing.
14. All food ingredients used in the CFO products are from an approved source.
15. Potable water shall be used for hand washing, ware washing and as an ingredient.
16. Is your water source a private water supply (well, spring, surface)?
❑
Yes No
® ❑
a. If YES, have you completed testing for bacteria, nitrate & nitrite?
❑
❑
17. Is your water source a public water system or community services district?(�
a. If YES, what is the name of the system or district? aD&d (0 V"a �6
0hC1
j❑�
1
During the preparation, packaging or handling of CFO products:
Yes
No
18. Domestic activities such as family meal preparation, dishwashing, clothes washing or ironing,
El
cleaning or guest entertainment are excluded from the kitchen.
19. Infants, small children (younger than 12 yr. old), or pets are excluded from the kitchen.
®
❑
20. Smoking is excluded.
❑
21. Any person with a contagious illness is prohibited from working in the CFO.
❑
Labeling Requirements:
Yes
No
22. A copy of the label has been submitted to this Department for review and approval.
®
❑
23. 1 have attached a sample label.
❑
BY SIGNING BELOW YOU ARE CERTIFYING THAT YOU MEET THE REQUIREMENTS OF THE CALIFORNIA HOMEMADE FOOD
ACT, AB 1616 (GATTO), AS IT PERTAINS TO A "CLASS A" COTTAGE FOOD OPERATION. PRIOR TO MAKING ANY CHANGES,
I ACKNOWLEDGE THAT I MUST NOTIFY RIVERSIDE COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH OF ANY
INTENDED CHANGES TO THE ABOVE STATEMENT. -
COTTAGE FOOD OPERATOR CHECKLIST COMPLETED AN SUBMITTED BY:
DATE: OWNER/OPERATOR:,l/�D�
�-� SIGNATURE DRIVERSTCENSEIH EXP. DATE
BUSINESS TELEPHONE:�(QCi Li'`a�} 1 0�'�'7 HOME TELEPHONE: `)(-p
E-MAIL ADDRESS: _�f3CC '� � Cn �y�PJ.a � CO y,/�-
Rev 5/2013 Page 2 of 2
COUNTY OF RIVERSIDFIM
DEPAWMENT OF ENVIROIVMENTAL HEALTH
CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)
COTTAGE FOOD OPERATION (CFO)
REGISTRATION / PERMITTING FORM
CFO Business Name .Date•
C Ccl�(e �a 3 7�/�Is
q I tq(3
CFO Physical Address:
��y,(d�C
CFO City
C�
CFO ZIP:
z3
Owner Name:
��
Owner Phone:
Owner Cell:
Mailing Address (if different):
Candy
Mailing City:
Mailing ZIP:
Email Address:
c� VVI
Website:
Vinegar
1. Categories:
g "Class A" (Direct Sales Only) $145/year ❑ "Class B" ( Direct & Indirect Sales) $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 (Required for "Class A" CFOs Only)
4. Products:
Please check ALL of the items you will be preparing and/or sellintt
®
Baked Goods
❑I
Dried Pasta
❑
I Honey
❑
Popcorn
❑
Candy
❑ I
Dry Baking Mixes
❑
Mustard
❑
Vinegar
❑
Churros
❑
Waffle Cones .
❑
Tortillas
❑
Fruit Butter **
❑
Dried Mole Paste
❑
Herb/Spice Blends
❑
Pizelles
❑
Jams/Jellies**
❑
Trail Mix
❑
Fruit Tamales/Pies
❑
Nuts/Nut Mixes
❑
Dried Fruit
❑
Fruit Empanadas
❑
Nut Butters
❑ 1
Dried Tea
❑
Roasted Coffee
❑
Sweet Sorghum Syrup
❑ I
Granola/Cereals
®
Chocolate Covered Nonperishable Food
❑
Other:
**These items must comply with standards described in Part 150 of Title 21 of the Code of Federal Regulations
h ://www.accessdata.fda. ov/scri ts/cdrh/cfdocs/cfCFR/CFRSearch.cfn?CFRPart=150
Food descriptions:
Rev. 05/13 Page 1 of 4
f
5. Product Labeling: Initift 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 the Federal, Food, Drug, and Cosmetic Act (21 U.S.C.
Sec. 343 et seq.) The label must include:
• The words "Made in a Home Kitchen" in 12-point type.
• The name commonly used to describe the food product.
• 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.
• 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.
• The ingredients of the food product, in descending order of predominance by weight, if the product contains
two or more ingredients.
• The net quantity (count, weight, or volume) of the food product. It must be stated in both English units
(pounds) and metric units (grams).
• 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
summary statement immediately following or adjacent to the ingredient list, or 2) within the ingredient list.
• 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. Specific 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.
• Labels must be legible and in English (accurately translated information in another language may accompany
it).
• 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.
• Sample of label must be submitted prior to final approval.
MADE IN A HOME KITCHEN
Permit M 12345
Issued in county: County name
Chocolate Chip Cookies With Walnuts
Sally's Treats
Anywhere, CA 925XX*
Ingredients: Enriched flour (Wheat flour, niacin, reduced iron, thiamine,
mononitrate, riboflavin and folic acid), butter (mile, salt), chocolate chips
(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts, sugar,
eggs, salt, artificial vanilla extract, baking soda.
Contains: Wheat, eggs, mile, soy, walnuts
Net Wt. 3 oz. (85.049g)
* Full address required for cottage food operations not currently listed in the local
telephone directory
Page 2 of 4
6. Water Source:
• •
Please idents the water source to be used in Cottage Food Facility (Check one box only)
5q Name of Public Water System or Community Services District:
❑ If you use a Private Water Supply*, identify the source (well, spring, surface, etc.):
Private Water Supply: 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
your local area office for details.
7. Disposal of Waste:
Please check what type of treatment is used to dispose of waste
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 and approval
to operate is issued.
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.
* Riverside County Food Handler Course will meet this requirement: www.rivcoeh.org
9. Employee: Initial if you agree to abide by the following:
I understand that I may not have more than one full-time equivalent cottage foo 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:
I understand that I will lose my CFO status and will need to become permitted -in a conunercial 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
In2013....................................................................... $35,000
In2014....................................................................... $45,000
In 2015 and in subsequent years ................................ $50,000
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It. Delivery Limitations: Initiioyou 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. Zoning Requirements: Initial if you agree to abide by the following: AAL
I understand that I must comply with all applicable zoning requirements for the jurisdi ion in which I live.
I have attached documentation from the Planning office (if required).
13. Owner's Statement:
I,7C1-Uv\.ck agree to grant access to the local health department to conduct an
inspection of my cottage food operation (mark one):
0 "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 reported food-
borne illness.
1,0 CIC&IyV C4 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
O rodu s to the consumer or retailers, regardless of whether the product is sold, consigned, or given away.
�,n,PIC /0eV (-7QuV�ai ZJ to / /3
Owner's Signature Print Name Date
OFFICE USE ONLY
AMT RECD: DATE RECD:
I INVOICE#:
PAYMENT TYPE: CASH I El CREDIT/DEBIT CHECK I CHECK#:
DRIYERS LICENSEk
EXPIRATION DATE:
SAMPLE LABEL RECEIVED BY -
COPY OF PLANNING APPROVAL RECEIVED BY:
ONSITE CFO INPECTION COMPLETED BY.
DATE:
CFO APPROVED BY.
I DATE:
FA #.- I PR#. SR#:
I PE#.
Page 4 of 4