"Meat Safety Compliance License Application" - Arizona

Meat Safety Compliance License Application is a legal document that was released by the Arizona Department of Agriculture - a government authority operating within Arizona.

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For AZDA/ASD Use Only
Arizona Department of Agriculture (AZDA)
New License No.
Central Licensing
(Cash) or Check #
1688 W. Adams, Phoenix, AZ 85007
Check Date
Line No.
Phone: (602) 542-6408 Fax: (602) 542-0466
ID No.
Meat Safety Compliance License Application
Pursuant to A.R.S. 3-2009 and 3-2081
Application must include applicant’s name and address, the business name and address, the physical location where the business is
to be conducted, and must be accompanied by the fee payment. All licenses expire on December 31
st
of each year.
License Type Information
(Please select one.)
Fee:
(Engages in the negotiation of third party meat & poultry product sales, for a commission.)
BROKER
$450.00
(Receives and distributes inspected meat & poultry products and conducts no processing.)
DISTRIBUTOR
$500.00
SMALL DISTRIBUTOR
$150.00
(Does not to exceed $100K in sales per calendar year. See above definition for distributor.)
JOBBER
$450.00
(Buys and sells meat & poultry products to other than end-users, does not process.)
PET FOOD MFG.
$300.00
(Manufactures meat & poultry products not for human consumption.)
RENDERER
$0.00
(Renders, tallows, or engages in the processing of pelts, hides and related.)
TRANSPORTATION
$300.00
(Engages in the intrastate transporting of perishable meat & poultry products.)
MEAT STORAGE
$450.00
(Stores perishable meat & poultry products.)
Applicant Information
Application Date:_________________
Address:__________________________________
Name of Applicant:___________________________
__________________________________
Applicant’s Title:_____________________________
City:_______________ State:_____ Zip:________
Applicant’s Social Security No:__________________
Applicant’s Phone No:_______________________
OR Company Tax Identification No:______________
Business Information
Name of Company:___________________________________________________________________________
Mailing Address
Physical Plant Address
Address:___________________________________
Address:__________________________________
___________________________________
___________________________________
City:_________________ State:_____ Zip:________
City:________________ State:_____ Zip:________
Company Contact:____________________________
Company Contact’s Phone No:__________________
The Arizona Department of Agriculture (AZDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or a part of an individual’s income is derived from any public assistance
program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication
of program information (Braille, large print, audiotape, etc.) should contact AZDA’s MPI Program Manager at 602-542-6398. To file a
complaint of discrimination contact the AZDA MPI Program Manager, 1688 W Adams, Phoenix, AZ 85007 or call 602-542-6398
(voice) or 1-00-367-8939 (TTY Relay Service), or USDA, Director, Office of Civil Rights, 1400 Independence Ave, S.W., Washington
DC 20250-9410 or call 1-800-720-5964 (voice) or 202-401-0216 (TDD) or 800-795-3272. AZDA is an equal opportunity provider and
employer.
I DO HEREBY DECLARE THIS REPORT IS TO THE BEST OF MY KNOWLEDGE TRUE, CORRECT AND COMPLETE.
_______________________________
___________________________________ _______________
Please Print Name
Signature
Date
For AZDA/ASD Use Only
Arizona Department of Agriculture (AZDA)
New License No.
Central Licensing
(Cash) or Check #
1688 W. Adams, Phoenix, AZ 85007
Check Date
Line No.
Phone: (602) 542-6408 Fax: (602) 542-0466
ID No.
Meat Safety Compliance License Application
Pursuant to A.R.S. 3-2009 and 3-2081
Application must include applicant’s name and address, the business name and address, the physical location where the business is
to be conducted, and must be accompanied by the fee payment. All licenses expire on December 31
st
of each year.
License Type Information
(Please select one.)
Fee:
(Engages in the negotiation of third party meat & poultry product sales, for a commission.)
BROKER
$450.00
(Receives and distributes inspected meat & poultry products and conducts no processing.)
DISTRIBUTOR
$500.00
SMALL DISTRIBUTOR
$150.00
(Does not to exceed $100K in sales per calendar year. See above definition for distributor.)
JOBBER
$450.00
(Buys and sells meat & poultry products to other than end-users, does not process.)
PET FOOD MFG.
$300.00
(Manufactures meat & poultry products not for human consumption.)
RENDERER
$0.00
(Renders, tallows, or engages in the processing of pelts, hides and related.)
TRANSPORTATION
$300.00
(Engages in the intrastate transporting of perishable meat & poultry products.)
MEAT STORAGE
$450.00
(Stores perishable meat & poultry products.)
Applicant Information
Application Date:_________________
Address:__________________________________
Name of Applicant:___________________________
__________________________________
Applicant’s Title:_____________________________
City:_______________ State:_____ Zip:________
Applicant’s Social Security No:__________________
Applicant’s Phone No:_______________________
OR Company Tax Identification No:______________
Business Information
Name of Company:___________________________________________________________________________
Mailing Address
Physical Plant Address
Address:___________________________________
Address:__________________________________
___________________________________
___________________________________
City:_________________ State:_____ Zip:________
City:________________ State:_____ Zip:________
Company Contact:____________________________
Company Contact’s Phone No:__________________
The Arizona Department of Agriculture (AZDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or a part of an individual’s income is derived from any public assistance
program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication
of program information (Braille, large print, audiotape, etc.) should contact AZDA’s MPI Program Manager at 602-542-6398. To file a
complaint of discrimination contact the AZDA MPI Program Manager, 1688 W Adams, Phoenix, AZ 85007 or call 602-542-6398
(voice) or 1-00-367-8939 (TTY Relay Service), or USDA, Director, Office of Civil Rights, 1400 Independence Ave, S.W., Washington
DC 20250-9410 or call 1-800-720-5964 (voice) or 202-401-0216 (TDD) or 800-795-3272. AZDA is an equal opportunity provider and
employer.
I DO HEREBY DECLARE THIS REPORT IS TO THE BEST OF MY KNOWLEDGE TRUE, CORRECT AND COMPLETE.
_______________________________
___________________________________ _______________
Please Print Name
Signature
Date