Application For Retail Food Sanitation License Form printable pdf download

Application For Retail Food Sanitation License Form

MISSISSIPPI

Department of Agriculture and Commerce

CONSUMER PROTECTION DIVISION

P.O. Box 1609

Jackson, MS 39215-1609

No. _________________

APPLICATION FOR RETAIL FOOD SANITATION LICENSE

The undersigned applicant hereby applies for a license to engage in business as a Retail Food Store, as defined and required by

Section 69-1-18 Mississippi Code of 1972, as amended, for any establishment who engages in business as a retail food store.

Full Name of Retail Food Store:

Current License Number:

Store Physical Address:

City:

State:

Zip:

Store Mailing Address if Different from above:

City:

State:

Zip:

Store Telephone No.

County

E-mail Address, Fax Number:

Important information for Food Safety Notification.

If corporation or partnership, give exact title and attach separate list of partners and/or officers.

If Corporation: In what state incorporated:

Corporation phone No.:

Principal office in State of Mississippi or resident agent:

Corporation’s agent for Service of Process:

Type of establishment (please check appropriate blank):

a. Full Service Grocery Store________

b. Convenience Store**______________

c. Other (explain)_________________________________________

**If Convenience Store, does applicant prepare or serve food? If so, please explain:______________________________

__________________________________________________________________________________________________

(All Applicants Must Complete Back of Application)

Application For Retail Food Sanitation License Form