Fillable Commonwealth of Massachusetts Application for Licensure to Process Poultry Within Scope of Mobile Poultry Processing Unit (MPPU) Pilot

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Commonwealth of Massachusetts Application for Licensure to Process Poultry Within Scope of Mobile Poultry Processing Unit (MPPU) Pilot

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The Commonwealth of Massachusetts Application for Licensure to Process Poultry Within Scope of Mobile Poultry Processing Unit (MPPU) Pilot form is 2 pages long and contains:

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Application for Licensure
to Process Poultry within scope of Mobile Poultry Processing Unit (MPPU) Pilot
in Accordance with M.G.L. C. 94,
§ 120 and/or 105 CMR 530.000 and 532.000
and in Accordance with Exemptions Associated with the Federal Poultry Products Inspection Act
Return to: Food Protection Program, 305 South Street, Jamaica Plain, MA 02130
USDA PLANT NUMBER_________________
EXEMPT FROM USDA
Instructions:
• Complete the entire two page application form.
• Submit a separate application for each facility to be licensed.
• Attach a separate check for each license application, made
payable to: The Commonwealth of Massachusetts.
• License fee is $225.00 annually.
1. Business Name
1.A Please include D.B.A. (Doing Business As):
2. Telephone #:
( ) Ext.______
3. Type of processing equipment being used (i.e. type of MPPU or other)
4. Mailing Address:
Email Address (mandatory):
_______________________________
5. Facility Address where processing will occur:
6. Telephone #:
( ) Ext.______
7. Responsible Contact Person:
8. 24- Hour Emergency Telephone #:
( ) Ext._______
9. Establishment # if federally
inspected:
Ownership
Name
Address
10. Individual:
11. Partnership:
A.
B.
A.
B.
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
305 South Street, Jamaica Plain, MA 02130-3597
(617) 983-6712 (617) 524-8062 - Fax
Provide Check or
Money Order Number:
12. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
13. If Applicant is a Corporation:
A) State of Incorporation:
B) Date of Incorporation:
14. Firm will Operate
Hours per Week?
Hours per Day?
15. Estimated Number of Animals to be Slaughtered Weekly/Seasonally
Capons
Turkeys
Geese
Ducks
16. Indicate Which Federal USDA Exemption being claimed for license period
Producer
Grower/1000
limit
Producer
Grower/20,000
limit
Producer Grower
or Other
Person/PGOP
Small Enterprise
Other
17. Estimated Volume of Product to be Prepared and Processed Weekly
End Product
Total Numbers to be Produced
Total Numbers Annually
Whole chicken
Whole turkey or ducks
Other (specify)
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 (ies) for which I am
applying. In addition, pursuant to M.G.L. Chapter. 62C, s. 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 to Process Poultry Within Scope of Mobile Poultry Processing Unit (MPPU) Pilot

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Completed 14 May 2020

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