Fillable Commonwealth of Massachusetts Application for Initial Licensure for Food Processing and/or Distribution at Wholesale

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Commonwealth of Massachusetts Application for Initial Licensure for Food Processing and/or Distribution at Wholesale

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The Commonwealth of Massachusetts Application for Initial Licensure for Food Processing and/or Distribution at Wholesale form is 2 pages long and contains:

  • 0 signatures
  • 5 check-boxes
  • 64 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Instructions:
• Complete the entire two-page application form.
• Submit a separate application for each facility or activity to be licensed.
• Attach a separate check for $300.00 for each license application, made
payable to: The Commonwealth of Massachusetts.
1. Firm’s Legal Name:
2. Telephone #: ( ) Ext._____
Fax #: ( )
3. D.B.A. (Doing Business As):
4. Mailing Address:
5. Facility Address (if different from Mailing Address):
6. Telephone #: ( ) Ext._____
Fax #: ( )
7. Responsible Contact Person:
8. Twenty-four (24) Hour Emergency Telephone #: ( )
Email Address (mandatory): __________________________________
9. Primary Food Processing Operation at This Facility (check one):
Seafood and/or Shellfish Dairy Products Baked Goods No food processing
Meat and/or Poultry Frozen Desserts Multiple Foods
10. Other Operations at this Location:
Wholesale Distribution Cold Storage Warehouse Packing and/or Repacking
Bottling Plant Warehouse
11. Type of Building (check one):
Non-Residential (i.e. commercial)
Residential (i.e. a kitchen in a private home that processes food for sale at wholesale)
On-Farm Processing (includes cottage food operations that process food for sale at wholesale)
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Food Protection Program
305 South Street, Jamaica Plain, MA 02130-3597
(617) 983-6712 (617) 524-8062 - Fax
Application for Initial Licensure
for Food Processing and/or Distribution at Wholesale
In Accordance with M.G.L. C.94, § 305C and/or 105 CMR 500.000
Return to: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
Provide Check or
Money Order Number:
12. Food Products to be Manufactured – Please identify the four most common food products to be manufactured at
this location, with each food’s product codes from the attached list:
(1) Food Product __________________________________ Product Code from List ______________________
(2) Food Product __________________________________ Product Code from List ______________________
(3) Food Product __________________________________ Product Code from List ______________________
(4) Food Product __________________________________ Product Code from List ______________________
I hereby certify that the above information is true to the best of my knowledge and that I will comply with all applicable
laws and regulations of the Commonwealth of Massachusetts and the Department of Public Health pertaining to the
activity for which I am applying. In addition, pursuant to M.G.L. C. 62C, § 49A, I certify under the penalties of perjury
that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law.
________________________ _________________________________________________________________
Date
If applying as an Individual, your Social Security #:
Tax or Federal I.D.#: _________________________
APPLICATION FEE: $300.00 per SITE or ACTIVITY. Each site or activity requires a separate application form.
No license issued pursuant to this application shall be transferred or assigned.
Revised 06/17
Address
A.
B.
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A.
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B) Date of Incorporation:
// /
// /
Owner or Corporate Officer
(print name)
__________________________________
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Commonwealth of Massachusetts Application for Initial Licensure for Food Processing andor Distribution at Wholesale

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Completed 18 May 2020

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