A person who represents to the public that food for sale or a place of business is under rabbinical or other kosher supervision shall complete a statement about the rabbinical or other kosher supervision. The statement about rabbinical or other kosher supervision shall set forth: The name of the establishment; The date the statement was completed; The dates to which the supervision applies; The name of the rabbi or agency; The address of the rabbi or agency; The phone number of the rabbi or agency; The affiliation of the rabbi or agency; The frequency with which the rabbi or agency visits the establishment; and A general description about the rabbinical or other kosher supervision of the establishment. The statement about rabbinical or other kosher supervision shall be completed in addition to all disclosure statements required to be completed under Regulation .03 of this chapter. The completed statement about rabbinical or other kosher supervision shall be posted in the manner set forth in Regulation .05 of this chapter. The Division shall develop a form for the statement about rabbinical or other kosher supervision, and shall make it available at the request of a person.