Fsis 5200 2 Form – Fill Out and Use This PDF

FSIS FORM 5200-2, APPLICATION FOR FEDERAL INSPECTION

(Meat, Poultry, Siluriformes Fish, Egg Products, and Import )

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INSTRUCTIONS FOR COMPLETION OF FSIS FORM 5200-2

Complete all sections. Enter N/A if a section is not applicable. Use continuation sheet if needed on Page 7 and number the item. To submit electronically, access the FSIS Form 5200-2, Application for Federal Inspection, on the FSIS Forms page. Complete the electronically-fillable form and save the form on your hard drive. Print the form and sign it. Scan the form and e-mail the completed form to the Grant Curator in the appropriate District Office. For paper copies, send the signed application form to the Grant Curator at the District Office mailing address.

SECTION I. APPLICANT INFORMATION - (Page Three)

1.Date of Application: Put current date application is completed.

1a. Existing Establishment Number, if applicable.

2.Type of Application (check all that apply).

3.Type of Inspection (check all that apply).

4.Form of Organization (check applicable box).

5.If Corporation, Name of State where Incorporated.

6.Date Incorporated: Show month, date, and year, e.g., mm/dd/yyyy.

7.Name and Address of Corporate Headquarters.

8.Federal Employer ID #.

9.Dun & Bradstreet #, if applicable.

10.Firm's Code (Import Only).

11.Name of Applicant (person, firm, or corporation making application) and mailing address.

12.Telephone number and e-mail address of applicant.

13.Actual Name of Company and Physical Location Address of Establishment.

14.Telephone number and e-mail address of establishment.

SECTION II. ESTABLISHMENT INFORMATION - (Page Three)

15.Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection

16.Name and establishment number of other official establishments located in the same facility, if applicable.

17.Other names - Doing Business As (DBA). Use continuation sheet if necessary.

18.Month and year when establishment will be ready to operate under inspection.

SECTION Ill. TYPE OF OPERATIONS - Meat, Poultry, Siluriformes Fish, Egg Products, and Import Inspection - (Page Four)

19A. Check all applicable boxes of animals to be slaughtered at the establishment.

Check all applicable boxes for the types of products intended for processing operations at the establishment.

Check all applicable boxes to indicate the type of exempt activities and provide an attachment to explain how the activities will be separated by time or by space.

19D. Check all applicable boxes under JURISDICTION

20.Check all applicable boxes (EGG PRODUCTS INSPECTION ONLY)

21A. Check all applicable boxes for Species (IMPORT INSPECTION ONLY)

21B. Check all applicable boxes for Mode of Transportation (IMPORT INSPECTION ONLY) 21C. and 21D. Check all applicable boxes Types of Products (IMPORT INSPECTION ONLY)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT - (Pages Five and Six)

22.The applicant must provide a list of persons responsibly connected with the establishment. Include all partners, officers, directors, holders, or owners if 10% or more of its voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an attachment, if necessary .

23.Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

24.Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

25.Have conditions for receiving inspection been met (SSOP, Recall Procedures, HACCP) in accordance with 9 CFR 304.3 and 381.22? Check all applicable boxes.

26.Privacy Act Notice. Check appropriate box.

PLEASE READ AGREEMENT, CERTIFICATION, AND WARNING STATEMENT

27.Typed or written name and title of person signing application. (Must be listed in Block 22).

28.Signature: By signing your name in this block you are stating that the information provided is accurate and binding.

BLOCKS 29, 30, 31, 32, AND 33 - TO BE COMPLETED BY USDA, FSIS, OFO DISTRICT OFFICE ONLY

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According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0153. The time required to complete this information collection is estimated to average 10 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.

SECTION I.APPLICANT INFORMATION

2. Type of Application (check all that apply)

3. Type of Inspection (check all that apply)

4. Form of Organization (check applicable box)

Individual

Cooperative

Partnership

Corporation

Education Institution

Limited Liability

Other

Association

Company (LLC)

5.

If Corporation, Name of State or

6.

Date Incorporated

7. Name and Address of Corporate Headquarters

Territory where Incorporated

Name

mm/ dd/ yyyy

Address

8

Federal Employer ID#

9.

Dun & Bradstreet # (if applicable)

City

10. Firm's Code (Import Only)

Zip

State

Country

Code

11.Name of Applicant (person, firm or corporation making application) and mailing 12. Telephone number and e-mail address of applicant address

Name							phone
Address							e-mail
City
State			Zip		Country
			Code
13. Actual Name of Company and Physical Location Address of Establishment							14. Telephone number, mailing address and e-mail address of establishment
Name							phone
Address							mailing
							address
City
							e-mail
State			Zip		Country
			Code

SECTION II. ESTABLISHMENT INFORMATION

15.Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection. Use continuation sheet or attachment if necessary. (For egg product plants, submit blueprints via electronic attachment or by mail.)

18.Estimated date when the establishment will be ready to operate under inspection (mm/ dd/ yyyy)

FSIS FORM 5200-2 (11-18-2015)

Previous Editions are Obsolete

SECTION III. TYPE OF OPERATIONS

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19. MEAT, POULTRY, AND SILURIFORMES FISH INSPECTION ACTIVITIES

(check all that apply)

19A. SLAUGHTER

19B. PROCESSING

19C. EXEMPTIONS (explain separation

19D. JURISDICTION (explain

OPERATIONS

OPERATIONS

separation from inspected

from inspected products on continuation

products on continuation sheet)

sheet)

Calf

a.

Fully Cooked - Not Shelf Stable

Custom Processing

FSIS Inspection only

Cattle

b.

Heat Treated Not Fully Cooked -

Custom Slaughter

State Inspection

Not Shelf Stable

Equine

c.

Retail Activities

Talmadge-Aiken

Heat Treated - Shelf Stable

Goat

d.

Not Heat Treated - Shelf Stable

Religious Exempt Poultry

Multiple Agencies

Sheep

e.

Product with Secondary

Swine

Inhibitors - Not Shelf Stable

Buddhist eviscerated Poultry

N/A

Chicken

f.

Raw - Intact Products

Confucian Non-eviscerated

Dual Jurisdiction

g.

Raw - Non Intact Products

Duck

Poultry

Establishment with Food

Islamic (Halal) Poultry

and Drug Administration

Goose

h.

Thermally Processed

(FDA)

Guinea

Commercially Sterile

Kosher Non-eviscerated Poultry

USDA Agricultural

Marketing Service

Ratite

(AMS) Grading/Quality

Religious Exempt Livestock

Control

Squab

Establishment provides

Halal

products for the National

Turkey

Kosher

School Lunch Program

Siluriformes Fish

Other (specify on continuation

sheet)

20. EGG PRODUCTS INSPECTION (check all that apply)

21. IMPORT INSPECTION (check all that apply)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT (continued)	Page 6

23.Enter the name of each person listed in Block 22 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 fraud in connection with transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of the conviction and the court in which convicted. If none, check the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

24.List each conviction against the applicant or recipient (person, firm or corporation) in any Federal or state court of any (1) 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 transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of conviction and the court in which convicted. If none, check the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

25. Check appropriate boxes if conditions for receiving inspection have been met in accordance with 9 CFR 304.3 and 381.22 for meat and poultry inspection only. Check all applicable boxes. (Does not apply to egg product inspection.)

26. Applicant has been provided with a copy of the Privacy Act Notice?

AGREEMENT AND CERTIFICATION: If inspection is granted under the application, I (we) expressly agree to conform strictly to the Federal Meat Inspection Act (21 U.S.C. 601 et seq.), or the Poultry Products Inspection Act (21 U.S.C. 451 et. seq.), or the Egg Products Inspection Act, (21 U.S.C. 1031 et. seq.), and the regulations governing the inspection of the meat, poultry or egg product inspection of the United States Department of Agriculture (9 CFR Part 301 et. seq.). I CERTIFY that all statements made herein are true to the best of my knowledge and belief.

WARNING: Persons knowingly and willfully making false, fictitious, or fraudulent statements or entries are subject to $10,000 fine or imprisoned not more than five years, or both, as prescribed by Title 18 U.S.C. 1001. This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, religion, sex, national origin, age or handicap, write immediately to the Secretary of Agriculture or the Administrator, FSIS, Washington, DC 20250.

TO BE COMPLETED BY USDA FSIS OFO DISTRICT OFFICE ONLY