Application for License to Transport
Bakery Products into the Commonwealth for the Purpose of Sale
In Accordance with M.G.L. C.94, § 305E
Return To: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
• Complete the entire two-page application form.
• Submit a separate application for each facility or activity to be licensed.
• Enclose copy of recent inspection report performed by appropriate
state agency.
• Attach a separate check for $300.00 for each license application, made
payable to: The Commonwealth of Massachusetts.
2. Telephone #: ( ) Ext._____
Fax #: ( )
3. D.B.A. (Doing Business As):
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. On an attached sheet, list each product brand name, where manufactured and the type of product to be shipped.
10. Name, Address and Telephone # of Local Representative:
NOTE: If your product is being distributed from a facility located in Massachusetts, that facility must have a
Wholesale Food Distribution license issued by the Department.
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
Provide Check or
Money Order Number:
