Partner/Manager If Corporation / List Partners If Partnership / Individual ( ) Partnership ( ) LLC / /
Currency
USD / /
Facility
Retail Food Store / Store Physical Address / Other (explain)_________________________________________ If Convenience Store / NO If Convenience Store / Store Telephone No. County E-mail Address / Store Mailing Address / /
IndustryTerm
cooked food / food service / retail food store / food establishment / last retail food sanitation license / /
Organization
Food Safety / MISSISSIPPI Department of Agriculture / /
MISSISSIPPI Department of Agriculture and Commerce CONSUMER PROTECTION DIVISION P.O. Box 1609 Jackson, MS[removed]No. _________________