FSVP Verification checklist

Dear Valued Supplier,

To ensure compliance with Food Safety and regulatory standards from our sources of foreign suppliers, our ability to provide consistently safe and legal products to our customers we ask for your cooperation in completing the following questionnaire and returning it back to us.

The list of questions outlined is to better understand your company’s compliance and capabilities. We have also included requirements for labeling and packaging.

Thank you in advance for your cooperation.

Section 1. Requirements

a. Documents

We require a Continuing Letter of Guarantee from each supplier of food ingredients and/or food packaging be sent to us on Company Letterhead, indicating the suitability of supplied products for food use. These letters should be renewed in January of each year. Additional documentation requirements is listed below.

b. Additional documentation requirements are listed below.

Product Name & Description
Net Weight
# of units/count (if applicable)
Lot Number
Manufacturing Date / Best By Date
Ingredient List (including allergens)
Company Name & Address
Recommended storage (if applicable)
Specification/size (if applicable)
Color (if applicable)
Kosher Designation (if applicable)
Halal Designation (if applicable)
Product Specification Sheet (included with shipment)
No Ethyl alcohol present in ingredients or flavorings- statement (where applicable)

c. Packaging requirements

Packages of any type should be well sealed to prevent contamination or intrusion by pests during storage or transportation. Corrugated packaging containing raw materials intended for food use should have inner bags or liners made from a food-grade material.

Section 2. Questionnaire

We believe that by responding to our supplier questionnaire, you will strengthen our line of communication and help us understand your food safety programs. In some cases, a particular requirement may not apply to your specific operation. If so, please state in the response section the reason(s) for exclusion.

1) Food Safety Programs

a) Food Safety Plan / Hazard Analysis and Critical Control Points (HACCP) Program with supporting documents (Critical Control Points - CCP Checks, Annual Reassessment, Verification, Validation, Corrective Action records etc.)*

Yes
No

Please attached a copy of your Food Safety Plan / HACCP Plan with process flow chart.

Drop files here or

If no, please state reason:

b) Quality Control Program that records and documents QA/QC line checks on in-process and finished products verifying conformance to customer product specification*

Yes
No

If no, please state reason:

c) Supply Chain Program / Raw Material Inspection Program*

Yes
No

If no, please state reason:

d) Customer Complaint Program with investigation report: Root Cause(s), Corrective Action(s) and Preventive Action(s).*

Yes
No

If no, please state reason:

e) Quality Systems / Regulatory Compliance

i. Third Party Audit*

Yes
No

Date of last audit:*

Auditing Agency:*

Please attached a copy of your most recent third-party audit certificate with complete audit report.*

Drop files here or

ii. FDA Bio-Terrorism Facility Registration*

Yes
No

Please provide last 4 digits of registration #:

iii. California Dept of Health Services Registration*

Yes
No

Please provide registration #:

iv. Foreign Supplier Verification Program (if applicable)*

Yes
No

Foreign suppliers please provide DUNS #:

v. Glass and Brittle Plastic Policy*

Yes
No

vi. Employee Training Program*

Yes
No

If no, please state reason:

f) Allergen Information:

i. Does your facility have an Allergen Control Plan?*

Yes
No

ii. Does the facility store or process any of the following allergens:

Milk*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Eggs*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Fish*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Shellfish Crustacean (shrimp, crab, lobster)*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Tree Nuts (almonds, cashews, macadamia nuts, shea nuts, pistachios, pecans, walnuts, hazelnuts, brazil nuts)*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Peanuts*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Wheat*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

Soybeans*

Present in products supplied to us? (Yes / No)	Present in other products made on the same line? (Yes / No)	Present in facility? (Yes / No)

iii. If present, does the policy involves storage segregation of allergen containing ingredients?*

Yes
No

iv. If present, does the policy involves Sanitation Procedure and/or other preventive controls?*

Yes
No

If no, please state reason:

g) Sanitation, Pest, and Maintenance Program

i. Good Manufacturing Practices*

Yes
No

ii. SSOP / Master Cleaning Schedule*

Yes
No

iii. Pre-op Inspection*

Yes
No

iv. Environmental Monitoring Program*

Yes
No

v. Integrated Pest Management Program*

Yes
No

vi. Preventive Maintenance Program*

Yes
No

vii. Designated Chemical Storage Area*

Yes
No

If no, please state reason:

h) Process & Operational Controls

i. Raw Materials and Finished Product Spec Sheets*

Yes
No

Please provide most recent version Product Specification Sheet with nutrition information for each product supplied to The Coffee Bean & Tea Leaf.

Drop files here or

ii. Foreign Material Control / Metal Detectors in use*

Yes
No

iii. Documented Traceability and Recall Program*

Yes
No

iv. Mock Recall performed at least annually*

Yes
No

v. Documented Hold and Release Program*

Yes
No

vi. Documented Food Defense Program*

Yes
No

If no, please state reason:

i) Transportation and Distribution

i. Inbound and Outbound Shipment Inspection*

Yes
No

ii. FIFO Rotation Policy*

Yes
No

If no, please state reason:

j) Laboratory

i. Finished product testing performed by ISO 17025 accredited laboratory?*

Yes
No

ii. Ability to produce Certificate of Analysis per shipment?*

Yes
No

Please provide Certificate of Analysis (COAs) for each shipment of each product supplied to The Coffee Bean & Tea Leaf.

Drop files here or

If no, please state reason:

2) Additional Certifications:

a) Kosher*

Yes
No

b) Halal*

Yes
No

c) Organic*

Yes
No

d) Non-GMO*

Yes
No

e) Gluten-Free*

Yes
No

f) Vegan*

Yes
No

g) Fair Trade*

Yes
No

h) Other (please specify):

Please provide most recent certificates of each certification listed “Yes” above.

Drop files here or

3) Transparency in Supply Chain Information:

a) Does your company comply with the requirements of the California Transparency in Supply Chains Act?*

Yes
No

b) Does your company certify that the materials incorporated into products supplied to International Coffee & Tea, LLC comply with the laws regarding slavery and human trafficking of the country/countries in which we do business?*

Yes
No

Initials:

4) Contact Information:

Company Name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

*

Name	Title	Phone #	Email

Completed by:*

Date:*

Signature*

FSVP Verification checklist

FSVP Verification checklist

Section 1. Requirements