The Commonwealth of Massachusetts
Division of Standards
Application for Special License as a Hawker and Peddler
This form of application must be filled out as directed, duly signed, and returned to this office with the full amount of the fee, before a license will be issued.
CASH, CERTIFIED CHECK, REGISTERED CHECK OR MONEY ORDER: Make check payable to the Commonwealth of Massachusetts. Do not mail cash.
To the Director of Standards, 1 Ashburton Place, Rm 1115, Boston, MA 02108, 617-727-3480.
I, the undersigned, hereby apply for a SPECIAL STATE LICENSE TO PEDDLE
TYPE OF GOODS TO BE SOLD: ___________________________________________
NAME: _____________________________ SSN# OR FED ID#:__________________
CITY: __________________________________ STATE:_______ ZIP:______________
DATE OF BIRTH:___________________________ PHONE NO:__________________
- Have you had a license before? ___ YES ___ NO If yes, License Number __________________
- Do you use a motor vehicle? ___ YES ___ NO If Yes, License#: _________________
- Have you been convicted of any offense against the laws of this state or the ordinances or by laws of any city or town? ___ YES ___ NO if yes state fully the nature of the offense, the court where convicted, data of conviction and penalty imposed._____________________
- CERTIFICATE OF SERVICE
I enlisted or was inducted at ____________________ on _________________ 19___ and served in Company _________________, Regiment _________________________ in the service of the United States and remained in said service until the ______________ day of ________________, 19___, when I was honorably discharged by reason of _____ _____________________________________________________________________ the Naval Service on board the U.S.S.__________________________ or ___________ ________________ from the _____________ day of __________________, 19___, when I was honorably discharged, or released therefrom by reason of ________________ ___________________________________.
- PURSUANT TO MASSACHSUETTS GENERAL LAW CHAPTER 62C 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
CERTIFICATE OF CHARACTER:
(Must be signed by Chief of Police of the city or town in which applicant resides.)
I, the undersigned, ___________________ of the City/Town of ________________________
hereby certify that to the best of my knowledge and belief that, __________________________ the above named applicant, is of good repute for morals and integrity.
SIGNED:_________________________ Chief of Police_______________ Date:__________
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