Form Msa 54 PDF Details

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QuestionAnswer
Form NameForm Msa 54
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names59-i, SERIVCES, 1872, TEXAS

Form Preview Example

APPLICATION FOR TEXAS MEAT AND POULTRY

INSPECTION OR EXEMPTION

Meat Safety Assurance Unit

 

1. Type of Application

 

 

 

 

 

 

 

 

 

 

3.

 

Official Number Assigned/Reserved

 

 

New

 

 

Change of Location

 

 

 

 

4.

 

Date of Application

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

County

 

 

 

 

 

 

 

 

 

 

 

Change of Owner

 

Other (Specify)

 

 

 

 

 

 

 

 

 

Circuit

 

 

2. Type of Inspection/

 

 

 

2a. Other Operations to be

 

6.

 

Form of Organization

 

 

 

 

 

 

 

 

 

Exemption Required

 

 

 

Conducted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meat Inspection

 

 

 

Poultry/Rabbit Exemption

 

 

 

Individual

 

 

 

Cooperative Association

 

 

Poultry Inspection

 

 

 

Retail Operations

 

 

 

Partnership

 

 

 

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

Voluntary Inspection

 

 

 

Non-meat Food Manufacturing

 

 

Corporation*State in which incorporated

 

 

 

 

 

 

 

 

 

Custom Exemption

 

 

 

 

 

 

 

 

 

 

*Charter Number/Franchise Taxpayer ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Name, Address and Telephone No. of Applicant

 

 

 

 

8. Name, Address (Mail) and Telephone No. of Plant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

E-Mail Address

 

 

 

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Other Names (if any) Under Which Business Will Be Conducted

 

10. Plant Location (If different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Estimated Operating Schedule Requiring Inspection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days/Wk

 

Hours/Wk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Estimate Average Volume of Operation Per Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Number Slaughtered Per Week

 

 

Amenable Species

 

 

 

 

 

 

Voluntary Species

 

 

 

NONE

 

 

 

 

 

Cattle

 

Swine

 

Goats

 

 

 

Sheep

Poultry

 

Ratites

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under Inspection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under Exemption

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voluntary Inspection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Estimate Processing Volume in Pounds Per Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meat

 

Poultry

 

 

 

 

 

 

 

 

 

 

Inspected

 

 

 

 

Exemption

 

 

 

 

 

Voluntary

1)Processed meats, sausage, hamburger, etc.

2)Sliced Products (bacon, ham, etc.)

3)Boned fresh meat or poultry

4)Fabricated products (steaks, roasts, etc.)

5)Cured and/or smoked products

6)Other (Specify)

PRIVACY NOTIFICATION: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004).

Printed or Typed Name of Person Signing Application

Signature & Title of Owner, Partner or Authorized Officer Making this Application

MSA Central Office Use

 

 

 

 

 

 

 

 

Comptroller-Clear Account

 

Yes

 

No

 

 

59-i Issued___________

 

 

 

 

 

 

Date

 

Initial

Date

Meat Safety Assurance Unit

 

 

 

 

 

(Over)

 

MSA-54

Rev 03-18-08

 

 

 

 

 

 

 

 

13.List all persons responsible connected with applicant Include all partners,officers, and owners of 10 percent more of voting stock, and employees in a managerial or executive capacity in the business. Notify the Regional MSA Program Manager of any changes in the listing

(ATTACH ADDENDUM IF MORE SPACE IS NEEDED)

 

Address (Include Zip Code)

10% Or More Stock holder (if

Name

 

 

incorporated)

Title

 

Yes (X)

 

No (X)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Enter the name of each person listed under Item 13 who has been convicted in any Federal or State court of any felony. Enter the name of each person listed under Item 13 who has been convicted in any Federal or State court of 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, the date of conviction and the court in which convicted. If None, write "NONE."

15. 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 than one violationof 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"

."

AGREEMENT AND CERTIFICATION:If inspection or exemption is granted under this registration, I (we) expressly agree to conform strictly to Chapter 433 of the Health and Safety Code, the Regulations governing Meat Inspection (9CFR Part 301 et seq.) , and the applicable rules adopted by the Texas Department State Health Services. I CERTIFY that all statements made herein are true to the best of my knowledge.

In accordance with Federal law and U.S. Department of Agriculture policy, this institutionis prohibited from discriminatingon the basis of race, color, national origin, sex, religion, age, or disability. To file a complaint of discrimination,contact the U.S. Department of Agriculture,Director, Office of Adjudication and Compliance, 1400 Independence Avenue S.W., Washington, D.C. 20250-9410; or call (866) 632-9992 (toll free),

(202)260-1026, (202) 401-0216 (TDD), or (800) 877-8339 (TDD toll free). USDA and Texas HHS are equal opportunity employers and providers.

Printed or Typed Name of Person

Signature & Title of Owner, Partner or Authorized Officer

Signing Application

Making this Application

TO BE COMPLETED BY MEAT SAFETY ASSURANCE UNIT

Return Completed Application to: TEXAS DEPARTMENT OF STATE HEALTH SERIVCES

MEAT SAFETY ASSURANCE UNIT - Mail Code 1872

P.O. Box 149347

AUSTIN, TEXAS 78714-9347

Date Approved

Signature of Director, MSA

This establishment to be under Texas Meat & Poultry Inspection Act

Meat Safety Assurance Unit

MSA-54 Rev. 03-18-08

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