Application for License to Sell at Retail Motor Fuel and/or Lubricating Oil for 2015

FEE: $150.00

In accordance with the provisions of Massachusetts General Law Chapter 94 Section 295B,as most recently amended. This application form must be filled out as indicated, and duly signed and returned to the address below with a license fee of $150.00 before the license can be issued.

Make check payable to the Commonwealth of Massachusetts. Do not mail cash and no refunds.

Mail to: Division of Standards, One Ashburton Place, Room 1115, Boston, MA 02108

To the Director of Standards:

I / We ____________________________________________________________________
(Type or print name of owner of business)

A retail dealer engaged in the business of selling motor fuel and/or lubricating oil at retail, and being the owner of said business operating under the name of

_________________________________________________

located at (address)

____________________________________________________________________

City or Town:_________________________ Zip Code:______________

Phone _____________________ Email Address ___________________

Hereby make application for license in accordance with provisions of , Massachusetts General Law Chapter 94 Section 295B as most recently amended.

Social Security No. or Federal ID No. ________________________________________________________

Workmen's Compensation Policy No.

________________________________________________________

If RENEWAL, Please indicate previous owner or license number

____________________________________

Brand of Motor Fuel Sold:_______________________

Suppliers: ____________________________________

PURSUANT TO MASSACHUSETTS GENERAL LAW CHAPTER 63C, SECTION 49A I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO THE BEST OF MY KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER LAW.

 

___________________________________________________________________________________

Signature of Applicant

Date


_________________________________________________________________________

Home Address, City or Town and Telephone

FEE: $150.00

 


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