Fillable Commonwealth of Massachusetts Application for Initial Licensure to Engage in the Sterilization/Sanitization of Bedding, Upholstered Furniture and Filling Materials

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Commonwealth of Massachusetts Application for Initial Licensure to Engage in the Sterilization/Sanitization of Bedding, Upholstered Furniture and Filling Materials

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The Commonwealth of Massachusetts Application for Initial Licensure to Engage in the Sterilization/Sanitization of Bedding, Upholstered Furniture and Filling Materials form is 2 pages long and contains:

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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 and location
to be licensed.
• For each license application attach a separate check
for $300.00 made payable to: The Commonwealth
of Massachusetts.
1. Company Name:
2. Tel. #: ( )
Ext.____
Fax #: ( )
3. D.B.A. (Doing Business As):
4. Mailing Address:
5. Facility Address (if different from Mailing Address):
6. Tel. #: ( )
Ext.____
Fax #: ( )
7. Responsible Contact Person:
8. 24-Hour Emergency Telephone #: ( ) Ext.______
Email Address (mandatory): _________________________________
Ownership
Name
Address
9. Individual:
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
305 South Street, Jamaica Plain, MA 02130-3597
(617) 983-6712 (617) 524-8062 - Fax
Application for Initial Licensure
to Engage in the Sterilization/Sanitization of Bedding,
Upholstered Furniture and Filling Materials
in accordance with M.G.L. C.94, § 271 and 105 CMR 620.000
Return to: Food Protection Program, 305 South Street, Jamaica Plain, MA 02130
Provide Check or
Money Order Number:
Ownership
Name
10. Partnership:
A.
B.
A.
B.
11. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
12. If Applicant is a Corporation:
A) State of Incorporation:
The following information is to be included with the application for initial licensure. The information need
not be included with renewal applications, unless changes have been made in the location of the apparatus or
in the type of apparatus and method used.
13. Brand name of sanitizing compound used:
14. Sanitizing compound manufacturer’s name and address:
15. Attach to the application copies of the sanitizing compound’s technical literature and Product Safety
Date Information.
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 Owner or Corporate Officer
If applying as an Individual, your Social Security #: _____________________________
Tax or Federal I.D.#: ___________________________________
NOTE: Copies of the Massachusetts General Laws and the Code of Massachusetts Regulations may be
obtained from the State House Bookstore located in Boston (617-727-2834), Fall River (508-646-1374), or
Springfield (413-784-1376).
Revised 06/17
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Commonwealth of Massachusetts Application for Initial Licensure to Engage in the SterilizationSanitization of Bedding, Upholstered Furniture and Filling Materials

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Completed 21 May 2020

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