1. Food Manufacturer’s Information:
_______________________________________________________ __MA-________ ___________________
Manufacturer’s Name
MA Registration Number
___________________________________________________________________________ ___________________________________________________
Doing Business as Name (if other than above, and you wish this name to Contact Person’s Name
appear on the export certificate)
______________________________________________________________________ ___________________________
___
_________________________
Street Address Contact’s Phone Number
Fax Number
___________________________________________________________________________ ___________________________________________________
City State Zip Country Contact’s Email Address (mandatory)
2. Exporting Company’s Information: (if applicable)
______________________________________________________ _____________________________________
Exporting Company’s Name State License/Registration Number
_______________________________________________________________________________________________________________________________
Stre
et Address
________________________________________________________________________________ ______________________________________________
City State Zip Country Contact Person
_________________________ ________________________ ________________________________________
Contact’s Email Address
Contact’s Phone Number Fax Number
3. Notarization Required?
Yes No
4. Product Description: ________________________________________________________________________
Continue on additional page(s) as needed.
5. Send Certificate to: Manufacturer
Exporter
6. Send Certificate via: ___________________________________________ _______________________________________________________
7. Fees: Quantity of Certificates Requested __________ x $ 75.00 =
$ ___________________ (Total)
Signature Title
Date Tax or Federal ID#
Revised: 06/17
Attach a check made payable to the Commonwealth of Massachusetts and mail to the above address.
8. Signature: The undersigned verifies that all ingredients are approved for use by the USFDA or appear on the
GRAS list,
and each product is intended for human consumption and available for sale in the U.S. without restriction. 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 to the best of m
y knowledge and belief,
have filed all
state tax returns and paid all state taxes required under law.
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
Food Export/Certificate of Free Sale Application
Return To: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
______________________________________ ___________________________________ _______________ ________________________
// /
Provide Check or Money Order Number:
For expedited certificate(s), please provide a pre-paid Fedex, UPS label, or
envelope with this application. Please allow 21 days for processing.
click to sign
signature
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