Application For Retail Food Sanitation License Form (Page 2 of 2) in pdf

Application For Retail Food Sanitation License Form Page 2

The undersigned applicant hereby certifies that all statements, information or schedules attached hereto are hereby made a

part of this application and that all statements and information contained herein are true and correct, that applicant will

comply with the Mississippi Retail Food Sanitation Law and Regulations and allow access to the establishment for inspection

by the regulatory agency during the food establishment’s hours of operation and other reasonable times.

This the __________ day of ____________________, 20__________

______________________________________

ATTENTION

Full name of applicant (Print Name)

This completed application and a check or money

order, in the amount of $10.00 payable to the

______________________________________

Mississippi Department of Agriculture and

Applicant’s Signature

Commerce, should be mailed to the address

indicated at the top of the front page of this

application. Applications that are incomplete and/or

__________________________________________

the fee is not submitted will not be processed.

Title

__________________________________________

Firm name (If corporation)

NOTE: (1.) Application must be signed. If partnership, each partner must sign. If corporation, corporate name must be

signed in full with the officer’s name or name of agent authorized to sign the application and title.

(Office Use Only)

Do Not Write Below

(Date Received)

Check Number_____________________________

Amount Received___________________________

Application For Retail Food Sanitation License Form Page 2