Fillable MA Dept of Public Health: Application for Initial Licensure to Process Meat and Poultry

Fill Online, Printable, Fillable, Blank MA Dept of Public Health: Application for Initial Licensure to Process Meat and Poultry Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MA Dept of Public Health: Application for Initial Licensure to Process Meat and Poultry

On average this form takes 22 minutes to complete

The MA Dept of Public Health: Application for Initial Licensure to Process Meat and Poultry form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 89 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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.
n $225.00 under $10 Million in sales
n $375.00 over $10 Million in sales
1. Business Name:
2. Telephone #:
( ) Ext.______
3. D.B.A. (Doing Business As):
4. Mailing Address:
Email Address (mandatory):
_____________
_____________________________________
5. Facility Address (if different from mailing address above):
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.
12. Corporation:
A) President
B) Treasurer
C) Clerk
A.
B.
C.
A.
B.
C.
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
Application for Initial Licensure to Process Meat and Poultry
in Accordance with M.G.L. C. 94, § 120 and/or 105 CMR 500.000
Return to: Food Protection Program, 305 South Street, Jamaica Plain, MA 02130
Provide Check or
Money Order Number:
13. If Applicant is a Corporation:
A) State of Incorporation:
B) Date of Incorporation:
14. Plant will Operate
Days per Week?
Hours per Day?
15. Estimated Number of Animals to be Slaughtered Weekly
Cattle
Calves
Goats
Swine
Equine
Chickens
Capons
Geese
Ducks
16. Estimated Weekly Volume of Fresh Meat or Ready-to-Cook Poultry to be Disposed in Wholesale Sales
Beef
Veal
Goat Meat
Pork
Equine Meat
Chickens
Capons
Geese
Ducks
Guineas
17. Estimated Volume of Product to be Prepared and Processed Weekly
End Product
Total Pounds to be Produced
Total Pounds to be Sold Wholesale
Processed meats, sausages, etc.
Sliced products: bacon, ham, etc.
Edible fats processed
Fabricated steaks, meat and poultry
dinners and pies, etc.
Canned meat or poultry
Boned or cut fresh meat or poultry
Equine meat products
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 #: ____
___________________________________
TA
X
OR
F
E
D
E
RA
L
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
// /
// /
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MA Dept of Public Health: Application for Initial Licensure to Process Meat and Poultry

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document