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:______________
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:_______________________
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
Home Address, City or Town and Telephone
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