"Application for License to Operate an Abattoir and/or Meat Processing Plant" - Georgia (United States)

Application for License to Operate an Abattoir and/or Meat Processing Plant is a legal document that was released by the Georgia Department of Agriculture - a government authority operating within Georgia (United States).

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Georgia Department of Agriculture
Meat Inspection • 19 Martin Luther King, Jr. Dr., SW • Room 108
Capitol Square • Atlanta, Georgia 30334-4201
• 404-656-3673
• 404-463-1998
http://agr.georgia.gov
Facsimile
Gary W. Black
Directions for Completion of Application for Inspection Form
Commissioner
To:
All Interested Parties
From:
Mr. Aaron Knighton: Director
Please be advised that In accordance with Georgia law, Georgia Department of Agriculture policy; Federal law and U. S.
Department of Agriculture policy (our cooperating partner), this institution is prohibited from discrimination in its programs and
services on the basis of race, color, national origin, sex, religion, age, or disability. To file a complaint of discrimination, contact:
Equal Employment Opportunity Officer
USDA, Director, Office of Civil Rights
Ms. Virginia Phifer, Personnel Director
1400 Independence Avenue, S. W.
Georgia Department of Agriculture
Washington, DC 20250-9410
19 Martin Luther King Jr. Drive, Suite 300
OR
(800) 795-3272 (voice)
Atlanta, GA 30334
(202) 720-6382 (TDD)
(800) 282-5852 (voice)
(404) 656-3673 (voice)
For deaf and hard-of-hearing users, please call
through a Relay service (in Georgia, dial 711).
The following Web addresses can be accessed for more information :
Georgia Department of Agriculture
http://agr.georgia.gov/
Filing Complaints USDA:
https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer
Directions for Completion of Application for Inspection Form
Please complete all sections. If a section is not applicable, enter “N/A” or “none”. If additional
space is needed for any item, attach a sheet and number the item.
1.
Date of Application: Shall be the date on which the form is executed.
2. Type of Application: Check applicable block.
NEW -for previously unlicensed facility;
CHANGE OF OWNER-
licensed facility when any change in ownership is made regarding 10 percent or more of the business;
CHANGE OF
when
LOCATION- licensed facility when any change in physical or mailing address is made ownership;
OTHER
(Specify) -
any other Updates or corrections need to be made in the official application
3. Type of License Required: Check applicable block.
MEAT if the species is cattle, swine, sheep or goats
VOLUNTARY if reimbursable inspection of species non-amenable to the Meat Act are intended.
4. Exempted Activities: There are several possible entries:
Custom Slaughter (CS)
d. Islamic (IS)
a.
Custom Processing (CP)
e. Buddhist (BU)
b.
Kosher (KO)
f. Confucianist (CO)
c.
An applicant can show one or any combination of the six, if needed.
Form of Company Organization: Check applicable block.
5.
State Where Incorporated: Self-explanatory.
6.
Date Incorporated: Self-explanatory- Show month and year.
7.
Name and address of Applicant: Show official firm name and address. Enter Federal Employee
8.
identification number assigned by the Internal Revenue Service in the space provided.
Area Code and Telephone Number: Self-explanatory.
9.
1
This institution is an equal opportunity employer and service provider
Georgia Department of Agriculture
Meat Inspection • 19 Martin Luther King, Jr. Dr., SW • Room 108
Capitol Square • Atlanta, Georgia 30334-4201
• 404-656-3673
• 404-463-1998
http://agr.georgia.gov
Facsimile
Gary W. Black
Directions for Completion of Application for Inspection Form
Commissioner
To:
All Interested Parties
From:
Mr. Aaron Knighton: Director
Please be advised that In accordance with Georgia law, Georgia Department of Agriculture policy; Federal law and U. S.
Department of Agriculture policy (our cooperating partner), this institution is prohibited from discrimination in its programs and
services on the basis of race, color, national origin, sex, religion, age, or disability. To file a complaint of discrimination, contact:
Equal Employment Opportunity Officer
USDA, Director, Office of Civil Rights
Ms. Virginia Phifer, Personnel Director
1400 Independence Avenue, S. W.
Georgia Department of Agriculture
Washington, DC 20250-9410
19 Martin Luther King Jr. Drive, Suite 300
OR
(800) 795-3272 (voice)
Atlanta, GA 30334
(202) 720-6382 (TDD)
(800) 282-5852 (voice)
(404) 656-3673 (voice)
For deaf and hard-of-hearing users, please call
through a Relay service (in Georgia, dial 711).
The following Web addresses can be accessed for more information :
Georgia Department of Agriculture
http://agr.georgia.gov/
Filing Complaints USDA:
https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer
Directions for Completion of Application for Inspection Form
Please complete all sections. If a section is not applicable, enter “N/A” or “none”. If additional
space is needed for any item, attach a sheet and number the item.
1.
Date of Application: Shall be the date on which the form is executed.
2. Type of Application: Check applicable block.
NEW -for previously unlicensed facility;
CHANGE OF OWNER-
licensed facility when any change in ownership is made regarding 10 percent or more of the business;
CHANGE OF
when
LOCATION- licensed facility when any change in physical or mailing address is made ownership;
OTHER
(Specify) -
any other Updates or corrections need to be made in the official application
3. Type of License Required: Check applicable block.
MEAT if the species is cattle, swine, sheep or goats
VOLUNTARY if reimbursable inspection of species non-amenable to the Meat Act are intended.
4. Exempted Activities: There are several possible entries:
Custom Slaughter (CS)
d. Islamic (IS)
a.
Custom Processing (CP)
e. Buddhist (BU)
b.
Kosher (KO)
f. Confucianist (CO)
c.
An applicant can show one or any combination of the six, if needed.
Form of Company Organization: Check applicable block.
5.
State Where Incorporated: Self-explanatory.
6.
Date Incorporated: Self-explanatory- Show month and year.
7.
Name and address of Applicant: Show official firm name and address. Enter Federal Employee
8.
identification number assigned by the Internal Revenue Service in the space provided.
Area Code and Telephone Number: Self-explanatory.
9.
1
This institution is an equal opportunity employer and service provider
Location of Plant and Mailing Address if Different From Item 8: If the mailing address of Item 8
10.
is a P. O. Box number or the physical address is not at the facility, then show location of the
plant by street, number, miles from town or highway, etc.
Area Code and Telephone Number: Show plant’s actual telephone number(s).
11.
Name and Establishment Number(s) of Other Establishments Located in the Same Facility:
12.
Name of person(s) or firm name(s) and establishment number(s) which prepare products
within the same facilities of the applicant identified in Item 8.
Other Names Under Which Business Will Be Conducted: This refers to subsidiaries doing
13.
business under a different name than the applicant requesting inspection.
Day/Year Plant Will Operate: Includes both exempt and Inspected processes.
14.
Hours/Week Plant Will Operate: Includes both exempt and Inspected processes.
15.
Hours/Day Plant Will Operate: Includes both exempt and Inspected processes.
16.
Month and Year Plant Will Be Ready to Operate Under Inspection Program: A facility could
17.
start with non-exempt activities and intend to engage in inspected activities later. Self-
explanatory. There can be overlapping exempt and non-exempt reporting, e.g., an applicant
may have in Section 16, 8 hours exempt and 8 hours non-exempt. This does not necessary mean
the plant is scheduled to work 16 hours.
Animals Slaughtered: Check applicable block(s).
18.
Fresh Meat or Ready-to-Eat Products to be Disposed of in Commerce: Check applicable
19.
block(s).
Prepared or Processed When Inspection is Inaugurated: Check applicable block(s) if Meat
20.
products are processed. Note: If poultry is used as a minority ingredient in any product, please
check
and place a “P”, by each applicable
: ‘Poultry used as a minor ingredient”
m.
OTHER (specify)
entries in the categories a. through m.
List of Responsible Persons: Shall include person signing the application, owners, officers,
21.
directors, managers, or others in an executive capacity or holding more than 10% of voting
stock. Be sure to show name, title, social security number, date and place of birth, home
address and check in the space provided concerning holding of stock. This must be completed
prior to issuance of license.
Person(s) Convicted of a Felony: Self-explanatory, if none, write none.
22.
Convictions Against the Applicants: Self-explanatory.
23.
Person Signing Application: Applicant’s name should be typed or legibly printed.
24.
Signature: Applicant needs to sign in ink.
25.
Title: Title of applicant whose name appears in Blocks 24 and 25
26.
Submit application.
Section 3. Including Blocks 27 through 42 are to be completed by Georgia
Department of Agriculture personnel only.
2
This institution is an equal opportunity employer and service provider
GEORGIA DEPARTMENT OF AGRICULTURE
APPLICATION FOR LICENSE TO OPERATE
AN ABATTOIR AND/OR MEAT PROCESSING PLANT
INSTRUCTIONS: Completely fill out all parts of the applicant’s section and submit this application to:
For facilities not previously providing such services, you must also attach and
Director: Meat Inspection Section
submit three sets of plans (blueprints) and three sets of specifications of the
Georgia Department of Agriculture, Room 108
plant. Complete all sections. If a section is not applicable, you may enter N/A or
NONE. If additional space is needed for any item, please attach an additional
19 Martin Luther King, Jr. Drive, SW
sheet with the information appropriately labeled to the number of the
Atlanta, Georgia 30334-4201
corresponding item.
SECTION 1: (to be completed by APPLICANT for State Inspection Activities)
1. DATE OF
2. TYPE OF APPLICATION
3. TYPE OF INSPECTION
4. EXEMPT ACTIVITIES
CUSTOM
APPLICATION
NEW
REQUIRED
RETAIL
CHANGE OF OWNER
CHANGE OF LOCATION
MEAT
OTHER (Specify)
OTHER (Specify)
VOLUNTARY
5. FORM OF ORGANIZATION:
INDIVIDUAL
COOPERATIVE ASSOCIATION
PARTNERSHIP
CORPORATION
OTHER (Specify)
IF CORPORATION
6. NAME OF STATE WHERE INCORPORATED
7. DATE INCORPORATED (Month and Year)
8. NAME OF APPLICANT (Company Name) AND MAILING ADDRESS
FEDERAL EMPLOYER
9. AREA CODE
IDENTIFICATION NO.
TELEPHONE NUMBER
(Include Zip Code)
(Assigned by IRS)
(
)
10a. LOCATION OF PLANT AND MAILING ADDRESS IF DIFFERENT FROM ITEM 8 (Include Zip
11. AREA CODE
TELEPHONE NUMBER
Code)
(
)
12. NAME AND ESTABLISHMENT NUMBER OF OTHER
13. OTHER NAMES(If any) UNDER WHICH APPLICANT
ESTABLISHMENTS LOCATED IN THE SAME FACILITY
WILL ALSO CONDUCT BUSINESS
14. DAYS PER YEAR PLANT
15. HOURS PER WEEK PLANT
16. HOURS PER DAY PLANT
17. MONTH AND YEAR WHEN PLANT WILL BE
READY TO OPERATE UNDER INSPECTION
WILL OPERATE
WILL OPERATE
WILL OPERATE
EXEMPT
NON-EXEMPT
EXEMPT
NON-EXEMPT
EXEMPT
NON-EXEMPT
EXEMPT
NON-EXEMPT
18. ANIMALS TO BE SLAUGHTERED WHEN INSPECTION IS INAUGURATED
CATTLE
CALVES
SHEEP
GOATS
SWINE
OTHER(Specify)
19. FRESH OR READY – TO- EAT PRODUCTS TO BE DISPOSED OF IN COMMERCE
BEEF
VEAL
LAMB OR MUTTON
GOAT MEAT
PORK
OTHER (Specify)
20. PREPARED OR PROCESSED WHEN INSPECTION IS INAUGURATED
TYPE OF
a.
BREAKING/CUTTING (carcasses, primal cuts, etc.)
h.
CANNING (shelf stable, perishable, cans, pouches, glass)
PRODUCT
b.
BONING (manual boning meat)
i.
DRYING (pork cuts, beef cuts, sausage, dehydrated)
c.
MECHANICAL DEBONING (mechanical deboning meat
j.
CONVENIENCE ITEMS (entrees, dinners, pies, pizzas, etc.)
MEAT
d.
FABRICATING (roast, chops, ground beef, hamburger, etc.)
k.
SLICING (bacon, luncheon meats, sausage, etc.)
e.
CURING (port cuts, beef cuts, ham, etc.)
l.
FATSOILS (lard, tallow, shorting, margarines, etc.)
f
FORMULATION (fresh/cured sausages, loaves, patties mix, etc.)
m.
OTHER (specify)
g.
COOKING/SMOKING (pork cuts, beef cuts, sausage, loaves, etc.)
PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C. 552a) 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. 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.). Under this Act, 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 Act also
requires 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 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 up to $20,000 fine or 5 years imprisonment.
APPLICATION FOR INSPECTION FORM GAMIS 01-2010 (modified 10/10)
T
HIS INSTITUTION IS AN EQUAL OPPORTUNITY EMPLOYER AND SERVICE PROVIDER
APPLICATION FOR INSPECTION FORM GAMIS 01-2010 (modified 4/10)
21.
List all persons responsibly connected with the applicant. Include all owners, officers, or directors. Include holders or owners of 10 per centum or more of
voting stock, and employees in a managerial or executive capacity in the business. Any change in ownership resulting in an additional party or person(s)
controlling 10 per centum or more of the voting stock must be reported on an updated application for review and approval by the Director of Meat Inspection
or their designee within 30 days. Attach additional sheet listing all required information if needed.
NAME
SOCIAL
DATE OF
PLACE OF
PRESENT HOME ADDRESS
HOLDER OF
SECURITY
BIRTH
BIRTH
(Street and Number
10% OR MORE
TITLE
NUMBER
(City and State)
City, State, Zip code)
VOTING STOCK
(indicate if partner, manager)
(If Corp)
YES
NO
( X)
(X)
22. Enter the name of each person listed under Item 21 who has been convicted in any Federal of State court of any felony. Enter the name of each
person listed under Item 21 who has been convicted in any Federal of State court of more than one violation of any law, other than a felony, based upon the
acquiring, handling, or distribution of wholesale, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in
food. Include the nature of the crime, the date of conviction and the court in which convicted. If none write “None”
23. List each conviction against the applicant (person, firm, or corporation) in any Federal or State court of any felony. List each conviction against the
applicant (person, firm, or corporation) in any Federal or State court of more that 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, the date of conviction and the court in which convicted. If none write “None”
OWNER, PARTNER, or AUTHORIZED OFFICER making the Application.)
SECTION 2. (To be completed by
AGREEMENT AND CERTIFICATION: In compliance with O.C.G.A 26 - 2 - 200, et seq. and O.C.G.A. 4 - 4 - 40, et seq., I (We) hereby make application to the
Georgia Department of Agriculture for an Abattoir and/or Meat Processing Plant License. I (We) expressly agree if inspection is granted under this application, to
conform strictly with all applicable rules and regulations including: the “Georgia Meat Inspection Act” (O.C.G.A. § 26-2-60); the “Federal Meat Inspection Act” (21
U.S.C 601 et seq.); and humane slaughter requirements (OCGA O.C.G.A. § 26-2-110 and the “Humane Methods of Slaughter Act” - 7 U.S.C 19601 et seq.) . I (We)
agree to: cooperate fully with the inspection personnel of the Georgia Department of Agriculture; to adjust slaughter schedules as required; and adequately
maintain sanitation site, facilities and equipment. I (We) understand that the Georgia Department of Agriculture may withdraw or suspend the license for failure
to abide by all rules and regulations or failure to operate as scheduled. I (We) understand the license is not transferable. I (We) understand that any person(s)
willfully making false, factitious, or fraudulent statements of entries on this form may be subject to fines up to $ 20,000, imprisonment for up to five years
or both.
I (We) agree to all requirements above and certify that all statements made herein or true to the best of my knowledge.
24. TYPED NAME of PERSON SIGNING APPLICATION
SIGNATURE AND TITLE
25. SIGNATURE
26. TITLE
SECTION 3. TO BE COMPLETED BY GEORGIA DEPARTMENT OF AGRICULTURE PERSONNEL ONLY
ACTION
/
ACTION- E
/
SIGNATURE
INITIALS
DATE COMPLETE
NTER INTO
SIGNATURE
INITIALS
DATE
COMPLETE
27. A
D
R
34. A
to S
PPLICATION
ATE
ECEIVED
DD
AMPLING
D
ATABASE
28. E
F
35. A
to S
STABLISH
ILE
DD
LAUGHTER
D
ATABASE
29. R
N
36. A
to/ U
ESERVE
UMBER
DD
PDATE
E
D
STABLISHMENT
IRECTORY
30. N
S
37.
S
OTIFY
UPERVISOR
NOTIFY
UPERVISOR
A
S
RRANGE
TAFFING
31. R
S
S
38. A
ECEIVE
UPERVISOR
S
URVEY
PPLICATION PROCESSED
R
ECOMMENDATION
32. R
A
L
39. L
M
EVIEW AND
PPROVE
ABELS
ICENSE
AILED
33. A
to PBIS
40. COMPLETED/
DD
VERIFIED
41. SIGNATURE : D
M
I
P
M
42. DATE
IRECTOR OF
EAT
NSPECTION OR
ROGRAM
ANAGER
The Georgia Department of Agriculture, Meat Inspection Program is an equal opportunity employer and service provider program. If you believe you have been discriminated against because of race, color, national
origin, age, sex, religion or disability, please write or call immediately the GDA EEO Officer, Ms. Linda Coody, Personnel Director, Georgia Department of Agriculture, 19 Martin Luther King Jr. Drive, Suite 300,
Atlanta, GA 30334 [(800) 282-5852 (voice), (404) 656-3673 (voice ) For deaf and hard-of-hearing users, please call through a Relay service (in Georgia, dial 711) or USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S. W. Washington, DC 20250-9410 [(800) 795-3272 (voice), (202) 720-6382 (TDD). Public reporting burden for this collection of information is estimated to average 30 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.
APPLICATION FOR INSPECTION FORM GAMIS 01-2010 (modified 10/10)
T
HIS INSTITUTION IS AN EQUAL OPPORTUNITY EMPLOYER AND SERVICE PROVIDER
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