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Home My WebLink About1.11 USDA Processing ApplicationCollection of this information is voluntary. It is needed before Federal Inspection of meat and poultry is granted. It is used by FSIS to determine whether the applicant should be issued a grant of Inspection. (9 CFR 304.1 and 9 CFR 381.16) FORM APPROVED OMB 0583-0082 U.S. DEPARTMENT OF AGRICULTURE INSTRUCTIONS: FOOD SAFETY AND INSPECTION SERVICE Submit this application to the District Manager, Food Safety and Inspection Service, U.S, Department of APPLICATION FOR FEDERAL MEAT, Agriculture for applicable Inspection requests. Complete all sections. If a section is not applicable enter "N/A" POULTRY, OR IMPORT INSPECTION I or "None," If additional space is needed for any item, attach sheet and number the item. SECTION I (to be completed for Import or Domestic Inspection Activfties) 1. DATE OF APPLICATION 2. TYPE OF APPLICATION 13. TYPE OF INSPECTION REQUIRED 4. EXEMPTED ACTIVITIES 03/23/2015 ❑✓ NEW ❑ CHANGE OF ❑ CHANGE OF LOCATION ❑✓ MEAT ❑ IMPORT (specify) OWNERKO ❑ OTHER (Specify) 0 POULTRY 5. FORM OF ORGANIZATION ❑ INDIVIDUAL ❑ COOPERATIVE ASSOCIATION ✓❑ CORPORATION ❑ OTHER (specify) 6. IF CORPORATION; NAME OF STATE WHERE INCORPORATED ❑ PARTNERSHIP COlOradO 7. DATE INCORPORATED (Month and Year) 08/12 B. NAME OF APPLICANT (Company Name) AND MAILING ADDRESS (Include Zip Code) FEDERAL EMPLOYER IDENTIFICATION NO. Eagle Springs Meats LLC Srvice)gnedby Internal Revenue 1733 Railroad Ave Rifle, CO 81650 46-1284369 10a. LOCATION OF PLANT AND MAILING ADDRESS IF DIFFERENT FROM ITEM 8 (Include Zip Code) 482 County Rd 315 Silt,CO 81652 9. AREA CODE TELEPHONE NUMBER 954-249-5674 11. AREA CODE TELEPHONE NUMBER 970-876-2856 10b. ATTACH A DESCRIPTION OF THE LIMITS OF THE ESTABLISHMENT PREMISES THAT /S REQUESTED TO BE UNDER FEDERAL INSPECTION (e.g., Diagram, written narrative, or schematic) 12. NAME AND ESTABLISHMENT NUMBER OF OTHER ESTABLISHMENTS LOCATED IN THE 1 13. OTHER NAMES (If any) UNDER WHICH BUSINESS WILL BE SAME FACILITY CONDUCTED 14. DAYS PER YEAR 15. HOURS PER WEEK PLANT WILL 16. HOURS PER DAY PLANT WILL 17. MONTH AND YEAR WHEN PLANT WILL BE PLANT WILL OPERATE OPERATE OPERATE READY TO OPERATE UNDER INSPECTION PROGRAM EXEMPT I NON-EXEMPT 240 EXEMPT NON-EXEMPT 40 EXEMPT NON-EXEMPT 8 EXEMPT NON-EXEMPT 04/2015 SECTION II (to be Completed for Domestic Ins ection Activities) 18. ANIMALS TO BE SLAUGHTERED WHEN INSPECTION IS INAUGURATED Lu CATTLE ✓❑ CALVES ✓❑ SHEEP ✓❑ GOATS ✓❑ SWINE ❑EQUINES 2 J �Z LU = yo ❑✓ YOUNG CHICKENS ❑✓ MATURE CHICKENS TURKEYS ❑ GEESE ❑ DUCKS ❑ GUINEAS C7 19. FRESH MEAT OR READY -TO -COOK POULTRY TO BE DISPOSED OF IN COMMERCE 11 JW h w} BEEF❑� VEAL ❑✓ LAMB OR MUTTON GOAT MEAT PORK ❑EQUINE MEAT �Z ❑✓ YOUNG CHICKENS ❑✓ MATURE CHICKENS TURKEYS ❑ GOOSE ❑ DUCK ❑GUINEA vo 20. PREPARED OR PROCESSED WHEN INSPECTION IS INAUGURATED TYPE OF PRODUCT a.✓❑ BREAKINGCUTTING (carcasses, primal cuts, whole poultry, poultry parts etc.) h. ❑CANNING (Shelf stab/e, perishable, cans, pouches, glass! Z❑ MEAT b.❑ BONING (manual boning meat/poultry) i. ❑ DRYING (portk cuts,beefcuts, sausage, dehydratedproducts) y ❑ POULTRY c.❑ MECHANICAL DEBONING (mechanicaldeboningmeat/poultry) j, ❑ CONVENIENCE ITEMS (entrees, dinners, pies, pizzas etc.) W UD d.❑✓ FABRICATING (roast, steaks, chops, ground beef, hamburger etc.) k. E] SLICING (bacon, luncheon meats sausage etc.) ❑ BOTH CL W 0.0 CURING (pork cuts, beef cuts, turkey, ham etc.) 1. ❑ FATSOILS (lard, tallow, shortening, margarine etc.) f.❑ FORMULATING (fresh/cured sausages, loaves, poultry rolls, pattie mix etc.) m. ❑ OTHER (specify) g.✓❑ COOKING/SMOKING (pork curs, beef curs, sausage, loaves etc.) FSIS FORM 5200-2 (7/97) REPLACES FSIS FORM 5200-2 (5/89), WHICH IS OBSOLETE. FSIS FORM 5200-2 (REVERSE) SOCIAL SECURITY N0, DATE OF BIRTH LACE OF BIRTH (City and State) PRESENT HOME ADDRESS (Street and Number, City, State, Zip Code) HOLDER OF 10% OR MORE VOTING STOCK ell CarpJ SECTION III Ito be completed for Import Inspection Activities) _ 21. IMPORT INSPECTION ACTIVITIES Boston MA 6829 Queenferry Circle Boca Raton FL 33496 Y!9 J f. PROCESSED PRODUCTS h. POULTRY (Parts) a. CARCASSES b. FRESH d. COOKED BEEF FRESH/FROZEN ❑ RAW ❑ VENISON ❑. CUTS ❑ RESTRICTED HEATED COOKED ❑BEEF VEAL OTHER r BONELESS MFG MEAT ❑ UNRESTRICTED DRIED/SEMI-DRIED OTHER POULTRY SWINE (describe) ❑ (describe) ❑ SHEEP c. FROZEN MFG. MEATS e. CONTAINERS g. POULTRY (Whole Carcass) ❑ GOATS ❑ CUTS ❑ PERISHABLE ❑ RAW ❑ EQUINE ❑ BONELESS MFG MEAT ❑ SHELF STABLE ❑ COOKED SECTION IV (to be completed for Import and Domestic Inspection Activities) 22. List all persons responsibly connected with the applicant. Include all owners, partners, officers, directorS, holders or owners of 10 per centum or more of vmfnn ci-nek anri arnnlnu"o in n mananoriai nr a Ari viva rnnariiu in the h—in— Nnrifv Tha Nl Irirr MnnAnnr of onv rhannau in The IiAtinn nivnn. NAME ,fTLr lhra9rdrellaerrnur mane a SOCIAL SECURITY N0, DATE OF BIRTH LACE OF BIRTH (City and State) PRESENT HOME ADDRESS (Street and Number, City, State, Zip Code) HOLDER OF 10% OR MORE VOTING STOCK ell CarpJ - President Kenneth Sack 030-92-6230 10/03/1954 Boston MA 6829 Queenferry Circle Boca Raton FL 33496 Y!9 J General Manager - Mark Montgomery 522-33-0611 12/16/1961 Canon City Co 482 CR 315 Silt, CO 81652 23, Enter the name of each person listed under Item 22 who has been convicted in any Federal or State court of any felony. Enter the name of each person listed under Item 22 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." none 24. 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 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." none 25. SANITATION STANDARD OPERATING PROCEDURES HAVE BEEN DEVELOPED FOR THE YES ❑ NO ESTABLISHMENT IN ACCORDANCE WITH §416.12 OF THE REGULATIONS. (Check) 26. APPLICANT HAS BEEN PROVIDED WITH A COPY OF THE PRIVACY ACT NOTICE (Check) FVI YES ❑ NO 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.), the Regulations Governing the Meat Inspection of the United States Department of Agriculture (9 CFR Part 301 et seq.), or the Poultry Products inspection Act (21 U.S.C. 451 et seq.), and the Poultry Products Inspection Regulations (9 CFR 381 et seq.), or both / CERTIFYthat a// statements made herein are true to the best of my knowledge and belief. WARNING: Persons 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. Code 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, D.C. 20250. 27. TYPED NAME OF PERSON SIGNING APPLICATION SIGNATURE AND TITLE OF OWNER, PARTNER, OR AUTHORIZED OFFICER MAKING THIS APPLICATION 28. SIG TURE 29. TITLE Kenneth Sack President 30. OFFICIAL NUMBER ASSIGNED/RESERVED EST 38527 /P_ 38527 TO BE COMPLETED BY USDA 31. IS THIS PLANT PRESENTLY UNDER STATE INSPECTION (Completed by �District Office) ❑ YES I_'_.1 NO 32. DATE RECEIVED 33. DATE REVIEWED 34, THIS PLANT TO BE UNDER TALMADGE-AIKEN ACT J ❑ YES ❑ NO 35. SIGNATURE OF DISTRICT MANAGER 136. DATE FSIS FORM 5200-2 OMB DISCLOSURE STATEMENT 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer, OIRM, Room 404-W, Washington, D.C. 20250; and to the Office of Management and Budget, Paperwork Reduction Project (OMB No. 0583-0015), Washington, D.C. 20503. If the OMB number is not present, you are not obligated to complete the form. DIRECTIONS FOR COMPLETION OF FSIS FORM 5200-2 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. 3. Type of Inspection Required: Check applicable block. 4. Exempted Activities: There are several possible entries: a. Custom Slaughter (CS) b. Custom Processing (CP) c. Retail Exempt (includes restaurants) (RE) d. Kosher (KO) e. Islamic (IS) f. Buddhist (BU) g. Confucianist (CO) An applicant can show one or any combination of the seven, if necessary. 5. Form of Organization: Check applicable block. 6. State Where Incorporated: Self-explanatory. 7, Date Incorporated: Show month and year. 8. Name and address of Applicant: Show official firm name and address. Enter Federal employee identification number in the space provided. 9. Area Code and Telephone Number: Self-explanatory. 10a. Location of Plant and Mailing Address if Different From Item 8: If the mailing address of item 8 is a P.O. Box number, show location of the plant by street, number, miles from town or highway, etc. 10b. Attach a Description of the Limits of the Establishment Premises that is Requested to be Under Federal Inspection: Self-explanatory. 11. Area Code and Telephone Number: Show plant's actual telephone number(s). 12. Name and Establishment Number(s) of Other Establishments Located in the Same Facility: 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. 13. Other Names Under Which Business will be Conducted: This refers to subsidiaries doing business under a different name than the applicant requesting inspection. DIRECTIONS FOR COMPLETION OF FSIS FORM 5200-2 (Continued) * 14. Day/Year Plant Will Operate: Self-explanatory. * 15. Hours/Week Plant Will Operate: Self-explanatory. * 16. Hours/Day Plant Will Operate: Self-explanatory. * 17. Month and Year Plant will be Ready to Operate Under Inspection Program: 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 necessarily mean the plant is scheduled to work 16 hours. 18. Animals Slaughtered: Check applicable block(s). 19. Fresh Meat or Ready -to -Cook Poultry to be Disposed of in Commerce: Check applicable block(s) 20. Prepared or Processed When Inspection is Inaugurated: Check applicable block(s) for Meat, Poultry, or Both under type of product. If the "Both" block is checked, indicate whether the activity is for "M", "P", or "B" for entries A through M. 21. Import Inspection Activities: Fill in only if requesting for Import Inspection and then the application should be referred to International Programs. (Separate applications are needed for import requests and domestic requests.) 22. List of Responsible Persons: Shall include person signing the application, owners, officers, directors, managers, or others in an executive capacity. 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. 23. Person(s) Convicted of a Felony: Self-explanatory, if none, write none. 24. Convictions Against the Applicants: Self-explanatory. 25. Sanitation Standard Operating Procedures have been developed: Check applicable block. 26. Privacy Act Notice: Check appropriate block. 27. Person Signing Application: Applicant's name should be typed or printed. 28. Signature: Applicant needs to sign in ink. 29. Title: Title of applicant whose name appears in Blocks 26 and 27. 30. Official Number Assigned/Reserved: District Manager will complete. 31. Plant Presently Under State Inspection: District Manager will complete. 32 through 36: To be completed by USDA.