• Complete the entire two-page application form.
• Only complete this form if you are applying to use Dogs and Cats in research and
education. No other animals need to be listed as part of this application form.
• Submit a separate application for each institution seeking licensure.
• Attach a separate check for $50.00 for each license application, made payable to:
The Commonwealth of Massachusetts.
• All licenses expire on June 30th.
2. Tel. #: ( ) Ext._______
Fax #: ( )
3. D.B.A. (Doing Business As):
Current Massachusetts
License # (if applicable):
5. Facility Address (if different from Mailing Address):
6. Tel. #: ( ) Ext._______
Fax #: ( )
7. Responsible contact-person:
8. 24-Hour Emergency Telephone #: ( ) Ext. _______
E-mail Address (mandatory): _____________________________________
9. Name of individual administratively responsible for the institution:
10. Name of individual in charge of the animal research program:
11. Name of attending veterinarian:
12. Describe the corporation, or other form of organization of the institution, and
state the general nature and purpose of its activities:
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
Use Dogs or Cats In Research and Education
in Accordance with M.G.L. C.140, § 174D and 105 CMR 910.000
Return To: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
Provide Check or
Money Order Number:
