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    617-983-6770 - Fax

INSPECTION REQUEST
WHOLESALE/RETAIL SEAFOOD OPERATIONS

Name of Company:

	Date/Time requested for inspection:	
Business Address:

	Current Permit Number:	
City/Town, Zip 

	Telephone # and E-mail address (if available):	
Name of Owner:

	Make, Year and Registration # of Vehicle:	
TYPE OF PERMIT REQUESTED	
Retail Store:________
	Wholesale Truck:________	Wholesale Dealer:________	
PRODUCTS REQUESTED	
Finfish                   _____
	Scallop Meat          _____	Lobster/Crabmeat   _____	Bait                  _____	
Northern Shrimp   _____
	Shellfish                _____	Live Lobsters         _____	Other                _____	
ACTIVITIES REQUESTED* (WHOLESALE ONLY)	
Fish Processing   __________
	Lobster Processing   __________	Shellfish Processing  _______	

•	If a Wholesale Dealer, a HACCP plan has been completed and implemented (inspection will not be conducted if HACCP plan is not available for review).
Yes: ______ No: ______

________________________________________________			________________
	Signature of Applicant/Owner							Date

* Persons seeking approval for on-shore Wet Storage Activities must contact the FPP prior to requesting an inspection.

Revision: April 2012