Maine Department of Agriculture

Maine Department of Agriculture, Conservation & Forestry Division of Quality Assurance & Regulations Dept Use Only: 28 State House Station – Augusta Me 04333-0028 (207) 287-3841 Telephone (207) 287-5576 Fax Date Rec’d______Check No.______MAINE MILK DISTRIBUTOR LICENSE APPLICATION / FROZEN DESSERT MANUFACTURER LICENSE APPLICATION License No.______

Please check the appropriate

 MILK DISTRIBUTOR LICENSE  New License  Renewal

 FROZEN DESSERT MANUFACTURER  New License  Renewal

PLEASE CHECK APPROPRIATE BOX INDICATING ESTIMATED SALE OR DISTRIBUTION  Annual sales or distribution over 25 million pounds: $300.00  Annual sales or distribution of 10-25 million pounds: $150.00  Annual sales or distribution of 1-10 million pounds: $100.00  Annual sales or distribution of 100,000 to 1 millions pounds: $50.00  Annual sales or distribution of less than 100,000 pounds: $25.00

I do not wish to re-license Reason In accordance with 7 MRSA §2902 and rules adopted pursuant to 7 MRSA §2910, I hereby apply for a Milk Distributor License / Frozen Dessert Manufacturer License: Farm / Company Name:

Name of Applicant:

Address:

Town State MAINE Zip Code:

Physical Location: (if different than mailing address)

Phone Cell: Fax______E-Mail: PLEASE CHECK HERE □ IF YOU WOULD LIKE YOUR PRODUCT RESULTS EMAILED TO YOU. This application must be accompanied by the names and addresses of all permitted producers and all sources of supply used by the applicant. A satisfactory inspection shall be required before issuance of a license to milk distributors. See the enclosed form for your convenience PLEASE MAKE CHECK PAYABLE TO: TREASURER STATE OF MAINE Sales and distribution of milk and/or milk products are for within the State of Maine only. The annual sales and distribution shall be determined from the calendar year previous to the year for which the license is applied. Sales and distribution may be estimated for the month of December. Make check payable to "Treasurer, State of Maine". Please note whether PRODUCTS PRODUCED (Use separate sheet of paper if necessary)______your products are: HEAT TREATED ______PASTEURIZED or NOT- FOR ALL FROZEN DESSERT MANUFACTURERS: PASTEURIZED Check product(s) sold [ ] Ice Cream [ ] Ice Milk [ ] Gelato [ ] Other: Mix used: Mixed Purchased from: Ingredients added:

FOR ALL MILK DISTRIBUTORS WHO MANUFACTURE ON THEIR FARM: # ANIMALS IN HERD:______# MILKING ANIMALS IN HERD:______COW:______GOAT:______SHEEP: FOR MILK DISTRIBUTORS OF NOT PASTEURIZED MILK AND MILK PRODUCTS: DATE OF LAST TUBERCULOSIS TEST: DATE OF LAST BRUCELLOSIS TEST:

Signature(s): Date: