Fillable Commonwealth of Massachusetts Application for Licensure for Manufacture, Distribution, and/or Sale of Methyl or Wood Alcohol

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Commonwealth of Massachusetts Application for Licensure for Manufacture, Distribution, and/or Sale of Methyl or Wood Alcohol

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The Commonwealth of Massachusetts Application for Licensure for Manufacture, Distribution, and/or Sale of Methyl or Wood Alcohol 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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Application for Licensure for
Manufacture, Distribution, and/or Sale of Methyl or Wood Alcohol
in Accordance with M.G.L. C.94, § 303B
Return to: Food Protection Program, 305 South Street, Jamaica Plain, MA 02130
Instructions:
• Complete the entire two-page application form.
• Submit a separate application for each facility to be licensed.
• Attach a single check of $150.00 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):
7. Responsible Contact Person:
24- Hour Emergency Telephone #: ( ) Ext._____
Email Address (mandatory): __________________________________
Ownership
Name
Address
8. Individual:
9. Partnership:
A.
B.
A.
B.
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Tel: (617) 983-6712 Fax: (617) 524-8062
6. Telephone #:( )
Ext._____
Fax #: ( )
Provide Check or
Money Order Number:
Ownership
Name
Address
10. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
11. If Applicant is a Corporation:
A) State of Incorporation:
B) Date 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.#: _________________________
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 Licensure for Manufacture, Distribution, andor Sale of Methyl or Wood Alcohol

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Completed 14 May 2020

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