Fillable Commonwealth of Massachusetts Application for License to Transport Frozen Desserts and/or Ice Cream Mix into the Commonwealth for the Purpose of Sale

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Commonwealth of Massachusetts Application for License to Transport Frozen Desserts and/or Ice Cream Mix into the Commonwealth for the Purpose of Sale

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The Commonwealth of Massachusetts Application for License to Transport Frozen Desserts and/or Ice Cream Mix into the Commonwealth for the Purpose of Sale 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 to be licensed.
• Attach a copy of your most recent inspection report issued by the
responsible state or local agency.
• Attach a separate check for $300.00 for each license application,
made payable to: The Commonwealth of Massachusetts.
1. Business Name:
2. Tel. #: ( )
Ext.______
Fax #: ( )
3. D.B.A. (Doing Business As):
Current Massachusetts
License # (if applicable):
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:
10. Partnership:
A.
B.
A.
B.
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 License to
Transport Frozen Desserts and/or Ice Cream Mix
into the Commonwealth for the Purpose of
Sale
in Accordance with M.G.L. C.94, § 65H and/or 105 CMR 500.000
Return To: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
Provide Check or
Money Order Number:
Ownership
Name
Address
11. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
12. If Applicant is a Corporation:
A) State of Incorporation:
B) Date of Incorporation:
13. Names of brands and trade or corporation name, if any, under which the products are to be sold:
14. How is mix transported:
15. Is the mix purchased? Yes No If yes, from whom is the mix purchased?
16. Is the mix pasteurized? Yes No
17. Number of gallons of frozen desserts and/or ice cream mix to be sold in Massachusetts during the
licensing period:
18. Number of gallons of frozen desserts and/or ice cream mix sold in Massachusetts during the previous
licensing period:
19. Is the plant constructed and equipped as provided in the regulations (105 CMR 500.000)?
Yes No
20. Does the plant use a public water supply? Yes No
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 Feder
al 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 License to Transport Frozen Desserts andor Ice Cream Mix into the Commonwealth for the Purpose of Sale

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Completed 21 May 2020

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