Form BC-1 "Application for Inspection" - Iowa

What Is Form BC-1?

This is a legal form that was released by the Iowa Department of Agriculture and Land Stewardship - a government authority operating within Iowa. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2002;
  • The latest edition provided by the Iowa Department of Agriculture and Land Stewardship;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BC-1 by clicking the link below or browse more documents and templates provided by the Iowa Department of Agriculture and Land Stewardship.

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Download Form BC-1 "Application for Inspection" - Iowa

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IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
SUBMIT TO:
Meat and Poultry Inspection Bureau
Director
Meat and Poultry Inspection Bureau
APPLICATION FOR INSPECTION
Wallace Building
Form BC-1
Des Moines, IA 50319
Date Received (office use only)
1. DATE OF APPLICATION
2. TYPE OF APPLICATION
NEW
CHANGE OF OWNER
CHANGE OF LOCATION
3. MONTH & YEAR BUSINESS, PLANT OR
NAME CHANGE/ADDITION OF "d.b.a."
ESTABLISHMENT WILL BE READY TO OPERATE UNDER
OTHER (Specify Here)
INSPECTION PROGRAM.
4. TYPE OF INSPECTION REQUESTED
5. FORM OF ORGANIZATION
CHECK ALL THAT APPLY
INDIVIDUAL
OFFICIAL RED MEAT SLAUGHTER
CORPORATION
OFFICIAL PROCESSING (RED MEAT AND POULTRY)
PARTNERSHIP
CUSTOM RED MEAT SLAUGHTER/PROCESSING
COOPERATIVE ASSOCIATION
OFFICIAL POULTRY SLAUGHTER
OTHER (Specify Here)
EXEMPT POULTRY
6. IF CORPORATION, NAME OF STATE WHERE INCORPORATED
7. DATE OF INCORPORATION (Month and Year)
8. NAME AND ADDRESS OF APPLICANT
9. TELEPHONE NUMBER OF APPLICANT (Include Area Code)
10. TELEPHONE NUMBER OF BUSINESS (Include Area Code)
11. NAME,STREET LOCATION AND MAILING ADDRESS OF BUSINESS
12. COUNTY WHERE BUSINESS IS LOCATED
13. HOURS OF OPERATIONS
CUSTOM/
OPERATION
OPERATION
OFFICIAL
EXEMPT
START TIME
STOP TIME
(CHECK)
(CHECK)
MONDAY
TUESDAY
14. OTHER NAMES (if any) UNDER WHICH BUSINESS WILL BE CONDUCTED
WEDNESDAY
(Doing Business As "d.b.a.")
THURSDAY
FRIDAY
SATURDAY
SUNDAY
This is an equal opportunity program. If you believe you have been discriminated against because of
Note: Official Operations Monday- Friday 6:00am-6:00pm
race, color, national origin, age, sex, religion or handicap,write immediately to the Secretary of
Agriculture, or Administrator,FSIS, Washington, D.C. 20250.
BC1.xls
Assigned Est. No._____________
Page 1 of 2
11/29/01-rev. 8/02
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IOWA DEPARTMENT OF AGRICULTURE AND LAND STEWARDSHIP
SUBMIT TO:
Meat and Poultry Inspection Bureau
Director
Meat and Poultry Inspection Bureau
APPLICATION FOR INSPECTION
Wallace Building
Form BC-1
Des Moines, IA 50319
Date Received (office use only)
1. DATE OF APPLICATION
2. TYPE OF APPLICATION
NEW
CHANGE OF OWNER
CHANGE OF LOCATION
3. MONTH & YEAR BUSINESS, PLANT OR
NAME CHANGE/ADDITION OF "d.b.a."
ESTABLISHMENT WILL BE READY TO OPERATE UNDER
OTHER (Specify Here)
INSPECTION PROGRAM.
4. TYPE OF INSPECTION REQUESTED
5. FORM OF ORGANIZATION
CHECK ALL THAT APPLY
INDIVIDUAL
OFFICIAL RED MEAT SLAUGHTER
CORPORATION
OFFICIAL PROCESSING (RED MEAT AND POULTRY)
PARTNERSHIP
CUSTOM RED MEAT SLAUGHTER/PROCESSING
COOPERATIVE ASSOCIATION
OFFICIAL POULTRY SLAUGHTER
OTHER (Specify Here)
EXEMPT POULTRY
6. IF CORPORATION, NAME OF STATE WHERE INCORPORATED
7. DATE OF INCORPORATION (Month and Year)
8. NAME AND ADDRESS OF APPLICANT
9. TELEPHONE NUMBER OF APPLICANT (Include Area Code)
10. TELEPHONE NUMBER OF BUSINESS (Include Area Code)
11. NAME,STREET LOCATION AND MAILING ADDRESS OF BUSINESS
12. COUNTY WHERE BUSINESS IS LOCATED
13. HOURS OF OPERATIONS
CUSTOM/
OPERATION
OPERATION
OFFICIAL
EXEMPT
START TIME
STOP TIME
(CHECK)
(CHECK)
MONDAY
TUESDAY
14. OTHER NAMES (if any) UNDER WHICH BUSINESS WILL BE CONDUCTED
WEDNESDAY
(Doing Business As "d.b.a.")
THURSDAY
FRIDAY
SATURDAY
SUNDAY
This is an equal opportunity program. If you believe you have been discriminated against because of
Note: Official Operations Monday- Friday 6:00am-6:00pm
race, color, national origin, age, sex, religion or handicap,write immediately to the Secretary of
Agriculture, or Administrator,FSIS, Washington, D.C. 20250.
BC1.xls
Assigned Est. No._____________
Page 1 of 2
11/29/01-rev. 8/02
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APPLICATION FOR INSPECTION --- Form BC-1
(page 2)
CHECK TYPE OF OPERATION(S) CONDUCTED BY BUSINESS, PLANT OR ESTABLISHMENT
15. CUSTOM OPERATIONS
15a. SPECIES--CHECK ALL THAT APPLY
RED MEAT
POULTRY
VOLUNTARY SPECIES
15b. PROCESSES--CHECK ALL THAT APPLY
Custom Exempt Slaughter
Custom Exempt Processing
Retail Sales
16. OFFICIAL OPERATIONS
16a. SPECIES--CHECK ALL THAT APPLY
RED MEAT
POULTRY
VOLUNTARY SPECIES
16b. PROCESSES--CHECK ALL THAT APPLY
1. SLAUGHTER--all species
6. HEAT-TREATED--shelf-stable
7. FULLY COOKED--not shelf-stable
2. RAW PRODUCT--ground
3. RAW PRODUCT--not ground
8. HEAT-TREATED BUT NOT FULLY COOKED--not shelf-stable
4. THERMALLY PROCESSED--commercially sterile
9. PRODUCT WITH SECONDARY INHIBITORS--not shelf-stable
5. NOT HEAT-TREATED--shelf-stable
16c. Sanitation Standard Operating Procedures have been developed for the
Yes
No
establishment in accordance with 416.12 of the regulations. (check)
16d. HACCP Plans have been developed for all official procedures for the establishment
Yes
No
in accordance with 417 of the regulations. (check)
17. List all persons responsible in connection with this application. Include all partners, directors, holders or owners of 10 per centum or more of voting stock,
also employees in a managerial or executive capacity in the business. Notify the Director of the Iowa Meat and Poultry Inspection Bureau of any changes in the
listing given.
Holder of more than 10% of
Name
Title
Address
voting stock? (check)
YES
NO
18. Name if each person listed under Item 17 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 upon fraud in connection
with transaction in food. Include the nature of the crime, date of conviction, and the court in which convicted.
19. AGREEMENT AND CERTIFICATION: IF inspection is granted under this application, I (we) expressly agree to conform strictly to the Iowa Meat and Poultry
Inspection Act, Chapter 189A of the Code of Iowa, as amended, and also to the Regulations governing meat and poultry inspection promulgated under this Act.
I certify that all statements made herein are true to the best of my knowledge.
Typed/Printed Name of Person Signing Application
Signiture and Title of Owner or Authorized Official Making this Application
Signature/Date
Title
BC1.xls
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11/29/01 -rev. 8/02
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