FSIS FORM 5200-2 - APPLICATION FOR FEDERAL INSPECTION

FSIS FORM 5200-2, APPLICATION FOR FEDERAL INSPECTION

(Meat, Poultry, Siluriformes Fish, Egg Products, and Import)

Page 1

1. Date of Application: Put current date application is completed.

1a. Existing Establishment Number, if applicable.

2. Type of Application (check all that apply).

3. Type of Inspection (check all that apply).

4. Form of Organization (check applicable box).

5. If Corporation, Name of State where Incorporated.

6. Date Incorporated: Show month, date, and year, e.g., mm/dd/yyyy.

7. Name and Address of Corporate Headquarters.

8. Federal Employer ID #.

9. Dun & Bradstreet #, if applicable.

10. Firm's Code (Import Only).

11. Name of Applicant (person, firm, or corporation making application) and mailing address.

12. Telephone number and e-mail address of applicant.

13. Actual Name of Company and Physical Location Address of Establishment.

14. Telephone number and e-mail address of establishment.

15. Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection.

16. Name and establishment number of other official establishments located in the same facility, if applicable.

17. Other names - Doing Business As (DBA). Use continuation sheet if necessary.

18. Month and year when establishment will be ready to operate under inspection.

SECTION II. ESTABLISHMENT INFORMATION - (Page Three)

SECTION I. APPLICANT INFORMATION - (Page Three)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT - (Pages Five and Six)

22. The applicant must provide a list of persons responsibly connected with the establishment Include all partners, officers, directors, holders, or owners if 10% or more of its

voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an attachment,

if necessary.

23. Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

24. Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

25. Have conditions for receiving inspection been met (SSOP, Recall Procedures, HACCP) in accordance with 9 CFR 304.3 and 381.22? Check all applicable boxes.

26. Privacy Act Notice. Check appropriate box.

PLEASE READ AGREEMENT, CERTIFICATION, AND WARNING STATEMENT

27. Typed or written name and title of person signing application. (Must be listed in Block 22).

28. Signature: By signing your name in this block you are stating that the information provided is accurate and binding.

BLOCKS 29, 30, 31, 32, AND 33 - TO BE COMPLETED BY USDA, FSIS, OFO DISTRICT OFFICE ONLY

19A.

19B.

21B.

19D.

19C.

20.

21A.

21C. and 21D. Check all applicable boxes Types of Products (IMPORT INSPECTION ONLY)

INSTRUCTIONS FOR COMPLETION OF FSIS FORM 5200-2

Complete all sections. Enter N/A if a section is not applicable. Use continuation sheet if needed on Page 7 and number the item. To submit electronically,

access the FSIS Form 5200-2, Application for Federal Inspection, on the https://www.fsis.usda.gov/employees/hr-policies-systems/forms

page. Complete the

electronically-fillable form and save the form on your hard drive. Print the form and sign it. Scan the form and e-mail the completed form to the Grant Curator in

the appropriate District Office

. For paper copies, send the signed application form to the Grant Curator at the District Office mailing address.

SECTION Ill. TYPE OF OPERATIONS - Meat, Poultry, Siluriformes Fish, Egg Products, and Import Inspection - (Page Four)

Check all applicable boxes for the types of products intended for processing operations at the establishment.

Check all applicable boxes to indicate the type of exempt activities and provide an attachment to explain how the activities will be separated by time or by space.

Check all applicable boxes under JURISDICTION

Check all applicable boxes (EGG PRODUCTS INSPECTION ONLY)

Check all applicable boxes for Species (IMPORT INSPECTION ONLY)

Check all applicable boxes for Mode of Transportation (IMPORT INSPECTION ONLY)

For slaughter operations, check all applicable boxes of animals to be slaughtered at the establishment. For cell-cultured operations, check all applicable boxes

of animal cells to be harvested at the establishment.

Page 2

UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)

FOOD SAFETY AND INSPECTION SERVICE (FSIS)

OFFICE OF FIELD OPERATIONS (OFO)

PRIVACY ACT NOTICE

AUTHORITY FOR REQUESTING INFORMATION

Authority for requesting both personal and business information is contained in the Federal Meat Inspection Act

(21 U.S.C.601 et seq.) and the Poultry Products Inspection Act (21 U.S.C. 451 et seq.). Under these Acts, the

Secretary of Agriculture is authorized to determine the fitness of applicants for or recipients of inspection service

to engage in business requiring inspection. Your disclosure of personal information to aid in this determination is

mandatory. The Acts also require full and complete disclosure of records and information showing the

transactions of your business.

PURPOSE FOR WHICH THE INFORMATION WILL BE USED

This information is being requested to establish and record your identity as a responsible official of the business

and to determine your fitness to receive a Grant of Inspection.

ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION

In appropriate situations, a report containing the information you furnish may be referred to other federal, state,

local or foreign agencies charged with law enforcement or the investigation or prosecution of law violations.

EFFECTS OF FAILURE TO FURNISH INFORMATION

Failure to provide requested information may delay or interfere with your receiving inspection service and may

result in civil penalties of $100.00 per day against you or your business, as prescribed by (15 U.S.C. 50). In

addition, persons making false, fictitious, or fraudulent statements or entries are subject to a $10,000.00 fine or

imprisonment for not more than 5 years or both, as prescribed by (18 U.S.C 1001).

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, religion, sex, national origin,

age or disability, immediately contact USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave., S.W., Stop

9410, Washington, DC 20250-9410, Toll-Free: (866) 632-9992, Federal relay: (800) 877-8339, Spanish relay: (800) 845-6136, Fax: (202)

690-7442, Email: [email protected]

The Privacy Act of 1974 (5 U.S.C. 522A) requires that certain information be given to you when you are

requested to furnish personal information to a Government Agency. The required information is provided in this

Notice. The act does not apply, however, to business information about your firm.

APPLICATION FOR FEDERAL INSPECTION

(Meat, Poultry, Siluriformes Fish, Egg Products and Import Inspection)

SECTION I. APPLICANT INFORMATION

1. Date of Application

New

3. Type of Inspection (check all that apply)

Individual

Meat

4. Form of Organization (check applicable box)

5. If Corporation, Name of State or

Territory where Incorporated

8 Federal Employer ID#

10. Firm's Code (Import Only)

Change of Location

Cooperative

Association

Partnership

Poultry

Change of Ownership

Corporation Education Institution

Limited Liability

Company (LLC)

Other

Egg Products

Siluriformes Fish

Import

11. Name of Applicant (person, firm or corporation making application) and mailing

address

Name

Address

City

Zip

Code

State

12. Telephone number and e-mail address of applicant

13. Actual Name of Company and Physical Location Address of Establishment

on continuation sheet attached document previously submitted

6. Date Incorporated

9. Dun & Bradstreet # (if applicable)

e-mail

phone

7. Name and Address of Corporate Headquarters

16. Name and establishment number of other official establishments located in the

same facility (if applicable)

SECTION II. ESTABLISHMENT INFORMATION

17. Other names - Doing Business As (DBA) - Use continuation sheet

if necessary

Submit this application electronically, or by mail, to the Grant Curator at the appropriate

U.S. Department of Agriculture, Food Safety and Inspection Service, District Office.

Complete all sections. If a section is not applicable, enter N/A or None. If additional

space is needed for any items, use the continuation sheet provided or an attachment.

Number the item.

Other, specify:

mm/ dd/ yyyy

15. Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection. Use

continuation sheet or attachment if necessary.

by other means (mail, courier)

18. Estimated date when the establishment will be ready to operate under

inspection (mm/ dd/ yyyy)

Name

Address

City

Name

Address

City

Zip

Code

State

1a. Existing Establishment Number (if applicable)

U.S. DEPARTMENT OF AGRICULTURE

FOOD SAFETY AND INSPECTION SERVICE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The

valid OMB control number for this information collection is 0583-0153. The time required to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Country

Zip

Code

State Country

Page 3

2. Type of Application (check all that apply)

14. Telephone number, mailing address and e-mail address of establishment

phone

e-mail

mailing

address

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

Cell-Cultured

Calf

Cattle

Equine

Goat

Swine

Duck

Guinea

Squab

Turkey

Goose

Chicken

Sheep

19A. SLAUGHTER OR

HARVEST OPERATIONS

Raw - Non Intact Products

Raw - Intact Products

Thermally Processed

Commercially Sterile

Not Heat Treated - Shelf Stable

Heat Treated - Shelf Stable

Fully Cooked - Not Shelf Stable

Heat Treated Not Fully Cooked -

Not Shelf Stable

Product with Secondary

Inhibitors - Not Shelf Stable

19B. PROCESSING

OPERATIONS

Custom Processing

Custom Slaughter

Retail Activities

Buddhist eviscerated Poultry

Confucian Non-eviscerated

Poultry

Islamic (Halal) Poultry

Halal

Kosher

Religious Exempt Livestock

Religious Exempt Poultry

FSIS Inspection only

19C. EXEMPTIONS (explain separation

from inspected products on continuation

sheet)

19D. JURISDICTION (explain

separation from inspected

products on continuation sheet)

State Inspection

Talmadge-Aiken

Multiple Agencies

Dual Jurisdiction

Establishment with Food

and Drug Administration

(FDA)

USDA Agricultural

Marketing Service

(AMS) Grading/Quality

Control

Establishment provides

products for the National

School Lunch Program

20. EGG PRODUCTS INSPECTION (check all that apply)

c. Raw - Non-Intact

a. Fully Cooked - Not Shelf Stable

Poultry

Egg Products

Siluriformes Fish

Meat

21A. Species

21C. Types of Products

(egg products)

21D. Types of Products (meat and poultry only)

Liquid Eggs

Frozen Eggs

Dried Eggs

21B. Mode of Transportation

Rail Cars

Trucks

Ocean Vessel

Airline

Fully Cooked - Not Shelf Stable

Frozen

Heat Treated - Shelf Stable

Not Heat Treated - Shelf Stable

Perishable

Raw - Intact

Product with Secondary Inhibitors -

Not Shelf Stable

Raw - Non-Intact

Ground product

Other Non-intact

Cuts (including bone-in

and boneless meats)

Boneless and/or skinless parts

Other Intact

Carcasses

Beef

Goat

Mutton

Thermally Processed/Commercially

Sterile

Poultry

Equine

Lamb

Pork

Ratite

Veal-hide on

Veal

Soups

Other Ham

Corned (species)

Heat Treated - Not Fully Cooked -

Not Shelf Stable

N/A

19. MEAT, POULTRY, AND SILURIFORMES FISH INSPECTION ACTIVITIES (check all that apply)

Kosher Non-eviscerated Poultry

21. IMPORT INSPECTION (check all that apply)

Frozen from an APHIS restricted

country 9 CFR 94.4 (b)

Other (specify on continuation

sheet)

Ratite

Other,

specify:

SECTION III. TYPE OF OPERATIONS

Page 4

Siluriformes Fish

d. Egg Breaking

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

b. Heat Treated - Shelf Stable

22. The applicant must provide a list of persons responsibly connected with the establishment. Include all partners, officers, directors, holders, or owners of 10 percent or

more of voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an

attachment if necessary.

Last

Address

City

Country

e-mail

First

Title

Name and Title Present e- mail and home address

Last

Address

e-mail

First

Title

yes

Last

Address

e-mail

First

Title

yes

Last

Address

e-mail

First

Title

yes

Last Address

e-mail

First

Title

yes

Last

Address

e-mail First

Title

Holder of 10% or more voting

stock? (if corporation)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT

Page 5

State

Zip

Code

City

Country

State

Zip

Code

City

Country

State

Zip

Code

City

Country

State

Zip

Code

City

Country

State

Zip

Code

City

Country

State

Zip

Code

yes

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT (continued)

23. Enter the name of each person listed in Block 22 who has been convicted in any Federal or state court of (1) any felony, or (2) more than one violation of any

law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or fraud in connection with

transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of the conviction and the court in which convicted. If none, check

the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

Page 6

24. List each conviction against the applicant or recipient (person, firm or corporation) in any Federal or state court of any (1) felony, or (2) more than one

violation of any law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or

upon fraud in connection with transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of conviction and the court in which

convicted. If none, check the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

27. Typed or written

name and title of person

signing application

29. Is this establishment:

(check all that apply)

under State Inspection?

in the Cooperative Interstate

Shipment (CIS) Program?

to be under the Talmadge-

Aiken Act?

30. Date application

received by District Office

31. Official inspection number(s)

assigned by District Office

32. Signature of the

District Manager

33. Date

None Yes, explain

Developed written Sanitation Standard

Operating Procedures (SSOP)

Conducted a hazard analysis and developed a

Hazard Analysis and Critical Control Point

(HACCP) plan

AGREEMENT AND CERTIFICATION: If inspection is granted under the application, I (we) expressly agree to conform strictly to the Federal Meat Inspection Act

(21 U.S.C. 601 et seq.), or the Poultry Products Inspection Act (21 U.S.C. 451 et. seq.), or the Egg Products Inspection Act, (21 U.S.C. 1031 et. seq.), and the

regulations governing the inspection of the meat, poultry or egg product inspection of the United States Department of Agriculture (9 CFR Part 301 et. seq.). I

CERTIFY that all statements made herein are true to the best of my knowledge and belief.

WARNING: Persons knowingly and willfully making false, fictitious, or fraudulent statements or entries are subject to $10,000 fine or imprisoned not more than

five years, or both, as prescribed by Title 18 U.S.C. 1001. This is an Equal Opportunity Program. If you believe you have been discriminated against because of

race, color, religion, sex, national origin, age or handicap, write immediately to the Secretary of Agriculture or the Administrator, FSIS, Washington, DC 20250.

26. Applicant has been provided with a copy of the Privacy Act Notice?

Yes No

28. Signature

Developed written recall procedures

TO BE COMPLETED BY USDA FSIS OFO DISTRICT OFFICE ONLY

None Yes, explain

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

25. Check appropriate boxes if conditions for receiving inspection have been met in accordance with 9 CFR 304.3, 381.22, and 590.149 for meat, poultry, and

egg products inspection only. Check all applicable boxes.

(Does not apply to egg product inspection.)

Continuation Sheet for FSIS FORM 5200-2 Page 7

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete