Application For Retail Food Sanitation License - Mississippi Department Of Agriculture And Commerce

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MISSISSIPPI
Department of Agriculture and Commerce
CONSUMER PROTECTION DIVISION
P.O. Box 1609
Jackson, MS 39215-1609
No.
601-359-1148
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:
Store Physical Address:
City
State
Zip
Store Mailing Address if Different from above:
City
State
Zip
Store telephone No.
County: Store is Located
Give Owner’ s Name: if corporation or partnership, give exact title
If partnership:
NAME OF ALL PARTNERS
ADDRESS
AGES
If corporation: In what state incorporated
Corporation phone No.
OFFICERS
NAME
ADDRESS
President
Vice-President
Secretary
Treasurer
Chief Exec. Officer
(Form Continued on Back)

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