HomeMy WebLinkAboutFP-26A Application for Certificate of Registration(HCI)
Application for Certificate of Registration for Cleaning and Inspection of
Commercial Cooking and Exhaust Systems (FP-26A)
Department of Fire Services • P.O. Box 1025, 1 State Road, Stow, MA 01775 FP-26A Rev. 01/18
978-567-3375 • FAX 978-567-3199 • www.mass.gov/dfs
CHECK ONE: NEW RENEWAL HCI # _________ (for renewal only)
I. APPLICATION INSTRUCTIONS
Type or print all items on this form, sign the form where indicated.
As part of this application, you must provide the name, address, and Certificate of Competency (HC) number for each
person within your employ.
A separate application for registration shall be completed for each separate business location.
Forward with this application, one original inspection/cleaning sticker, and one original orange non-compliance
sticker.
II. APPLICANT INFORMATION
Name of Firm: Operating as of:___________________________
Month Day Year
Address of Firm: ______________________________________________________________________________________
Street Address of the CR Shop City/Town State Zip
Mailing Address (if different): ____________________________________________________________________________
Street and / or P.O. Box City/Town State Zip
Email Address of Contact Person: ______________________________________________________________________
(All renewal notices will be sent electronically, not by regular mail, effective immediately.)
Federal Employer Identification Number (FEIN):
Business Phone Number: ______________________________________________________________________________
III. LIST OF CURRENT EMPLOYEES (that possess a valid Certificate of Competency)
NAME ADDRESS HC #
1. ________________________________ ____________________________________ ____________________
2. ________________________________ ____________________________________ ____________________
3. ________________________________ ____________________________________ ____________________
4. ________________________________ ____________________________________ ____________________
5. ________________________________ ____________________________________ ____________________
6. ________________________________ ____________________________________ ____________________
7. ________________________________ ____________________________________ ____________________
8. ________________________________ ____________________________________ ____________________
9. ________________________________ ____________________________________ ____________________
10. _______________________________ ____________________________________ ____________________
If additional space is needed, list all other employees on a separate sheet of paper and attach it to this application.
Department of Fire Services • P.O. Box 1025, 1 State Road, Stow, MA 01775 FP-26A Rev. 01/18
978-567-3375 • FAX 978-567-3199 • www.mass.gov/dfs
IV. APPLICANT CERTIFICATION
I hereby certify that I have read and am familiar with 527 CMR 1.00: Section 1.13.8 pertaining to “Cleaning and Inspection
of Commercial Cooking and Exhaust Systems,” and 527 CMR 1.00: Chapter 50, relative to “Commercial Cooking”,
promulgated by the Board of Fire Prevention Regulations. I do further certify that I have read this application and affirm that
the statements contained in this application are true and correctly set forth. I also agree as a condition to the receiving of
said certificate of registration, that same may be revoked or suspended by the State Fire Marshal for any infraction of, or
failure to comply with all rules and regulations of the Board of Fire Prevention Regulations pertaining to the regulated
activity.
I hereby authorize the State Fire Marshal, or designee, to enter, examine, and inspect any premises, building, room,
establishment, and documents used in connection with the cleaning and/or inspection of commercial cooking and exhaust
systems to determine compliance with the provisions of state law and the regulations relating to the regulated activity.
Applicant intends doing business as: { } Individual { } Corporation { } Partnership
A. Sole Ownership:
Print Name:_____________________________ Signature:________________________________
B. Corporation: (Name of corporate officer authorized to execute this document)
Print President’s Name: Signature:
_______________________________________ ________________________________________
Print Vice President’s Name: Signature:
_______________________________________ ________________________________________
Print Secretary’s Name: Signature:
_______________________________________ ________________________________________
C. Partnership: (Name of partner authorized to execute this document)
Print Name:________________________________ Signature:_________________________________
All incomplete applications submitted to the Division of Fire Safety will be returned. Any delay in the Issuance of a license
or permit, due to an incomplete filing, will be the sole responsibility of the applicant.
I declare under the penalty of perjury that the statements and information provided herein are true as of the date of this
application. I am aware that there are significant penalties for submitting false information, including possible fines, civil
penalties and imprisonment.
Applicant Name: __________________________________________________
Applicant Signature: _______________________________________________ Date:______________________________