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) 524-8062 - Fax

Interstate Milk Shippers Check Rating Fee or Single Service Manufacturer Audit Fee in Accordance with 801 CMR 4.02
Return To:  Food Protection Program, 305 South St., Jamaica Plain, MA 02130

Please indicate either Check Rating or Single Service Audit

INTERSTATE MILK SHIPPERS CHECK RATING FEE  ($750.00)

SINGLE SERVICE MANUFACTURER AUDIT FEE ($300.00)

Instructions:
•	Complete both pages of the fee form.
•	Submit a separate form for each facility to be rated/audited.
•	Attach a separate check of  $750.00 for Interstate Milk Shippers check rating/$300.00 for Single Service audit made payable to:
The Commonwealth of Massachusetts.
•	Check Rating Fees are payable every two years and are non-refundable. A facility that is unable to maintain an acceptable rating must re-apply and submit the full Check Rating fee of $750.00.
•	Single Service Audit Fees are payable every two years and are non- refundable. A facility that is unable to maintain an acceptable audit must re-apply and submit the full Audit fee of $300.00.	
Provide Check or
Money Order Number:	
1.   Business Name:	2. Tel. #: ( 	) 	Ext.______

Fax #: ( 	)	
3.   D.B.A. (Doing Business As):	
4.   Mailing Address:	
5.   Facility Address (if different from Mailing Address):	6. Tel. #: ( 	) 	Ext.______

Fax #: ( 	)	
7.   Responsible Contact Person:	8.   24-Hour Emergency Telephone #: ( 	) 	Ext. 	  Email Address (mandatory): 				

Ownership	Name	Address	
9.  Individual:			
10.  Partnership:	
A. B.	
A. B.	
11.  Corporation:

A) President B) Treasurer C) Clerk	
A. B. C.	
A. B. C.	
12.  If Applicant is a Corporation: 	A)  State of Incorporation: 	B) Date of Incorporation:

/	/	
13. Names of brands and trade or corporation name, if any, under which the products are to be sold:	

I hereby certify that the above information is true to the best of my knowledge and that I will comply with all applicable laws and regulations of the Commonwealth of Massachusetts and the Department of Public Health pertaining to the activity for which I am applying. In addition, pursuant to M.G.L. C. 62C, § 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law.

_________/ ____/___________ 	_________________________________________________________________

Date 	Owner or Corporate Officer

(print name)

If applying as an Individual, your Social Security #:

_______________________________

Tax or Federal I.D.#:	 	

NOTE: Copies of the Massachusetts General Laws and the Code of Massachusetts Regulations may be obtained from the
State House Bookstore located in Boston (617-727-2834), Fall River (508-646-1374) or Springfield (413-784-1376).

Revised 06/17