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
Instructions:
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.
1. Business 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. 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:
Ownership
Name
11. Individual:
12. Partnership:
A.
B.
A.
B.
13. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
14. If Applicant is a Corporation:
A) State of Incorporation:
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.#: _____________________________________________
APPLICATION FEE: $300.00 per SITE or ACTIVITY. Each site or activity requires a separate application form. No
license issued pursuant to this application sh
all be transferred or assigned.
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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