Form FSI-1098 "Application for Disposal Plant License - Article 5-c" - New York

What Is Form FSI-1098?

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

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the New York State Department of Agriculture and Markets;
  • 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 FSI-1098 by clicking the link below or browse more documents and templates provided by the New York State Department of Agriculture and Markets.

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Download Form FSI-1098 "Application for Disposal Plant License - Article 5-c" - New York

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FSI-1098 (1/17)
APPLICATION FOR DISPOSAL PLANT LICENSE – ARTICLE 5-
C
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No. __________________________
INSTRUCTIONS
NO LICENSE FEE REQUIRED
Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is
required in Section (8).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number:
OR
Social Security Number:
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title
Contact Address (Street & No., City, State, Zip)
Date of
Name (Please Print)
E-Mail address
Birth
(4a.) Principal Office Address: _______________________________________________________________________________________________
(4b.) In what state incorporated? _________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
FSI-1098 (1/17)
APPLICATION FOR DISPOSAL PLANT LICENSE – ARTICLE 5-
C
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No. __________________________
INSTRUCTIONS
NO LICENSE FEE REQUIRED
Read and complete both sides of this application.
Prepare a separate application for each location.
An original signature of owner or corporate officer is
required in Section (8).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number:
OR
Social Security Number:
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title
Contact Address (Street & No., City, State, Zip)
Date of
Name (Please Print)
E-Mail address
Birth
(4a.) Principal Office Address: _______________________________________________________________________________________________
(4b.) In what state incorporated? _________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
(5) Is applicant in compliance with all ordinances or local laws of the county, city, town and village in which such business or occupation will be
conducted?
Yes
No (if no, give details)
_______________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________
(6) Has applicant, or any partner, officer, director, holder or owner of 10% or more of the stock, or any person exercising any position of management or
control in the operation, previously been responsible, in whole or in part, for any act on account of which a disposal plant license has been or may be
denied, suspended or revoked? ______ Yes ______ No
(If yes, give details)
______________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
(7) VEHICLE IDENTIFICATION (Vehicles used in Disposal Plant Service)
YEAR AND MAKE
VEHICLE IDENTIFICATION
LICENSE PLATE NO.
a.__________________________________
___________________________________
__________________________________
b.__________________________________
___________________________________
__________________________________
c.__________________________________
___________________________________
__________________________________
d.__________________________________
___________________________________
__________________________________
e.__________________________________
___________________________________
__________________________________
f.___________________________________
___________________________________
__________________________________
g.__________________________________
___________________________________
__________________________________
(8) ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER TITLE DATE
Applicant represents that there are adequate physical facilities to conduct a disposal plant business at the address for which license application is made.
Applicant consents to free entry and will permit free access to licensed premises, buildings, vehicles, and offices and required records by the
Commissioner, the his agents, and inspectors in pursuance of the Commissioner’s duty to supervise and regulate those who deal in, handle, transport,
process or dispose of meat products regardless of origin which are adulterated.
Applicant understands the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.
The undersigned hereby applies for a license to operate a Disposal Plant to process dead, dying, diseased or condemned animals and meat or meat
products, regardless of origin, which are adulterated pursuant to the provisions of Article 5 of the Agriculture and Markets Law and regulations
promulgated there under.
Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application, may be
punishable under the provisions of Section 210.45 of the Penal Law of the State of New York.
NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that the applicant, licensee, officer,
director, partner or share/stockholder, has been convicted of, or has pled guilty to, a felony in any court of the United States or any State or territory
thereof, with respect to an offense involving; food safety, food adulteration or food misbranding.
Providing your signature below acknowledges your understanding of requirements listed herein and that you agree to comply with the requirements of
Article 5-C.
SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER
TITLE
DATE
AUTHORIZATION AND PURPOSE
Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New
York State Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and
others who have been delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by
the Tax Law administered by the Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by
the Tax Law. The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law in the sections
relating to the specific license you are seeking. This information is collected to enable the Department to evaluate your application, to
determine if it should be issued and to assist in the enforcement and administration of the Agriculture and Markets Law.
If you have questions about the information requested, call (518) 457-7139; e-mail agr.sm.foodlicense@agriculture.ny.gov; or write to: NYS
Department of Agriculture and Markets; Attn: Food Safety License Unit; 10B Airline Drive; Albany, NY 12235.
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