in Accordance with 801 CMR 4.02
Return To: Food Protection Program, 305 South St., Jamaica Plain, MA 02130
INTERSTATE MILK SHIPPERS CHECK RATING FEE ($750.00)
SINGLE SERVICE MANUFACTURER AUDIT FEE ($300.00)
• Complete both pages of the fee form.
• Submit a separate form for each facility to be rated/audited.
• Attach a separate check of $750.00 for Interstate Milk Shippers check
rating/$300.00 for Single Service audit made payable to:
The Commonwealth of Massachusetts.
• Check Rating Fees are payable every two years and are non-refundable. A
facility that is unable to maintain an acceptable rating must re-apply and
submit the full Check Rating fee of $750.00.
• Single Service Audit Fees are payable every two years and are non-
refundable. A facility that is unable to maintain an acceptable audit must
re-apply and submit the full Audit fee of $300.00.
2. Tel. #: ( ) Ext.______
Fax #: ( )
3. D.B.A. (Doing Business As):
5. Facility Address (if different from Mailing Address):
6. Tel. #: ( ) Ext.______
Fax #: ( )
7. Responsible Contact Person:
8. 24-Hour Emergency Telephone #: ( ) Ext.______
Email Address (mandatory):______________________________________
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
Interstate Milk Shippers Check Rating Fee
or Single Service Manufacturer Audit Fee
Please indicate either Check Rating or Single Service Audit
Provide Check or
Money Order Number:
