FEE $2.00

Office Use Only
HP___ No.____________
Issue Date_____________
Issued By:_____________

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#:__________________

ADDRESS: ______________________________________________________________

CITY: __________________________________ STATE:_______ ZIP:______________

DATE OF BIRTH:___________________________ PHONE NO:__________________ 

EMAIL ADDRESS:________________________________

  1. Have you had a license before? ___ YES ___ NO If yes, License Number __________________
  2. Do you use a motor vehicle? ___ YES ___ NO If Yes, License#: _________________
  3. 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._____________________
    ____________________________________________________________________
  4. 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 ________________ ___________________________________.
  5. 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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