Rev.01.2013 Republic ofthe Philippines Department of Agriculture NATIONAL MEAT INSPECTION SERVICE Visayas Ave, Diliman, Quezon City APPLICATION FOR THE ISSUANCE OF GMP/HACCP CERTIFICATE TO MEAT ESTABLISHMENTS 1. Food Safety Program | 2. Type of Audit ‘3. Type of Meat Establishment = GMP. Certification SLH __cs = Hacer = Renewal /Verification = pop = __McP ‘Surveillance MPP lose-Out jeat Establishment Profile Name of Owner/Operator, 0%: NO ¥1- PY Name of Companys =e and n Meat Establishment Address: Tachi, “TRE Accreditation No: _fVP" ¥2g- Email Add: _SHuceeageapent A CORAL CN 5. Documentation Packet 6. Payment Mode GMP: GMP /SSOP Manual GMP Certification P2,000 Pre-requisite Programs: MallingFee P165 Total Amount Paid = Calibration —Z Product iD system OR # —_ Date Istued Z Product Traceabil Zireticteal HACCP Cerf 00000/proauc TE traning MallingFee P2165 Tota Sustain ont Dat lsued Shien No. of Product/s: ‘Total Amount Paid “Zarpproved supplier Zaisss,wood and loose tems policy TZvssposal of Non-Conformaing Products hereby certify that the above statements are: HACCP: trueand correct tothe best of my knowledge and Product profile: documentary requirements submitted are complete. Scope of HACCP program Product description ingredients Z Process flow dlogram ZZ iizzara analysis & CCP determination TZ uacce Table (7 principles) TH, 9 ZZ HACCP Team/Management Commitment Date of Application Note: ‘© Documentation packets required for the Cerafeation (new) of both GMP/HACCP, © Product profile ic required per HACCP Product cenifieation NMIS ACKNOWLEDGEMENT RECEIPT: Date Received : (NMS Authorized Representath (Slgnatare over peeted nome)ts HUIS Fer Na A = 708 APPLICATION FORM OF MEAT ESTABLISHMENT NMIS LICENSE TO OPERATE (LTO) INSTRUCTIONS: 1, Only authorized company representative Is allowed to fill-up tho application form. Photocopy of the valid 1D of the applicant must be attached to this form, 2, The information provided In the application form MUST be complete, true and correct. 3. Tick (¥) mark the box that corresponds to the Info. Please do not leave any spaces blank, Indicate NIA If not applicable. Providing false Information statements Is punishable by law (RA10536). 3. Company Tax Identification Number (TIM) 1 Type of Appitcation 2 Type of Plant New Adattor/Saughterhouse: AP Private facility <7 Renewal 1 Staughterhouse wih Meat fabrication (1 Public facility Ungrading on ow, Poutry Dressing Plant 0) Unot 4. NMIS LTO No. Dressing with thor procnssing — (1 Lino 2 WP - y29- MA S Grete Copan heme S15 PRT Nef vexteatonetaseen Q/- Mehen Tagloon cari tiene] CAPT -7e45- Ob Fax, cag oe coe) Tewctorere 1s Tare 7 crt Corry Regan) —_ PGB WORRY Deaton ec Force Hayehoy Kimeya Jecaan hicanie Gier enatasoen {Sehapahnga@ gre) car leneacna, +_bff0s"4924- Ws /e949- 2094 “753 7 Ned eyamere ceeratan NITY) AN wo ofanniday 2 9-No.cthowssnn_ BHC 10 Neate of Arenal inigheredressed (headsidny) 11 Maximum production capac Scout femme! Average daiy slaughtered O Sere © cate 0 Corse 0 Goettnep O Corte O hone AT Pastry D Pebirg uct Doma: 1G Oters Pease wey) sores 12 Prepared (wth tatrxcaton) (Korot Woot ‘Average daly production Pet O Cuting Prot Volume Brand name D Beet 0) Detioning © Covabeetl) Mechanical toning MSM © Chevon 1D Crocedtio mostpy Reed NMS Fom No.4 ~2018 APPLICATION FORM OF MEAT ESTABLISHMENT NMIS LICENSE TO OPERATE (LTO) chicken Gtt ge 1 sol Anngroka O cues O Duck meat O stich mest Clothers Please specify) / 12 DesnatonDisrbyten : werntarets__Ely 6 / Bins Bakedny / Blin trig. or / Eline Digan / Tekroric Hotel Restavrantntaona Chen Cad Strape Shops swpemartes_ Wines Sogermatkey 7 Herel 7 Oh Bay 7 Cantnare Depet Ceters : 1. Sarge Capaaty ‘re cubic meters) No.of Units Capacity | crite \ tas Hey Bas Chiter aw Wa 9y 23 Fu Foidng Freezer asm Nesaiq, Helen AA Gey OterColdStorgeuse LED -Bm_ W=AAM, YazVH, 1 90.00 18. Convac/Tol Processor Company time Si IM testing Aout ae ~__ Bigg ORG, fale Rigger Cheat Eval atiress FRO cet ACG Cn saepnonetacna, :__ SA AGS ~ 16, Present status ef Labeling ‘re labeling packaging materials provided to contract processor? ET yes CI no (ees the label inate the contrac tl processor? Byes Ono D our Centicate 4 HACCP Cental xr LTO Certificate ORNo. ORN Not] ORNo: ol) Date issued: Date issu ‘einaty a Date issuge: Havel W Du2 a noun? UO a | hereby certity thatthe above statements are true and correct tothe best of my knowledge and documentary. complete and updated. (Please attached photocopy (back-to back vad Company 1D) Tis pana bo by KS hed esta 7 Date of Application: NAT he 39 TNNIS Authorized Represontatve (Signature over printed name)CORRECTIVE AND PREVENTIVE ACTION PLAN Name of Establishment: St. Jude Dressing Plant Establishment Address _: Brgy. Mohon Tagoloan Misamis Oriental T ‘Audit date: January 28, 2022 ‘Audit Type : For Surveillance Audit [] Individual accréditation []system accreditation _“) ‘Accréditation Number : por sbeda Date prepared (dd/mm/yyyy): February 23, 2022 { Vs ind Getfima Z. Cultura ‘Approved by : Dr. Lino M. Dy y ‘Owner/Management Representative {Name & Designation of establishment's authorized representative) Prepared by +: Rejie BOnJ; sor / Production Manager QC Supervisor / Production Su| ‘it’s authorized representative) (Name & Designation of establishi Evidence of Completion | rie | peepee, |" conechencen/ || Comemerioees meme | penn | tee ary (Please affix pone picture) | Preventive re (CAPA) after the institution of date Se ‘going/others) Corrective Action) | dd/mm/yyyy (7) (4) (5) ‘Structural Minor Findings: Follow-up Maintenance to January 28, PWaintenancéin=—) “Done /Corrected Handwashing facil adjust the Hot water, all 2022 charge observed to have inadequacy as | handwashing Facilities before ft ‘evidence of cold water running | start of operation from the faucet contrary to what is indicated in the handwashing manual and instruction. The system of ensuring that the | Inform the St. Jude ‘Conduct for ‘St.Jude On-going proper floor to wal management on the things to be Management observed to have defici requirements and scheduling done 2 | evidence of nteaved orto waljonton the all area and new holding room.— | and newholding room ‘As per NMIS Requirement GMPKi mn we NMIS CHECKLIST FOR NEW LICENSE TO OPERATE (LTO) OF MEAT semen we fs ara |LISHMENT. AIG \\ AMAIA (he Peon Lurene wast army i sotatieesning oem rea altima “ote rae LMS ~———_—_——————_—_—_—__ SSS ‘comnrre wcomrere levee pment of rere oes) (ren be cement 6 pint)