Form FP-081 "Application for License to Sell Black or Smokeless Powder" - Massachusetts

What Is Form FP-081?

This is a legal form that was released by the Massachusetts Department of Fire Services - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Massachusetts Department of Fire Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FP-081 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Fire Services.

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Download Form FP-081 "Application for License to Sell Black or Smokeless Powder" - Massachusetts

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Application for License to Sell Black or Smokeless Powder (FP-081)
NEW ______
RENEWAL SP# ______
I.
APPLICATION INSTRUCTIONS
Follow the instructions below to complete the Application for a License to Sell Black or Smokeless Powder:
1.
Type or print in black ink all items on this form and sign the form in Section V.
2.
Include a notarized statement on company letterhead indicating that these explosive
materials shall be stored according to the requirements of 527 CMR 1.00.
3.
Include payment of $100.00 for a NEW license made payable to the Commonwealth of
Massachusetts. Include payment of $50.00 for a RENEWAL license made payable to the
Commonwealth of Massachusetts.
4.
Include a legible copy of your current driver’s license.
5.
If you sell Black Powder, include a legible copy of your current ATF Permit.
6.
Complete and have notarized the CORI request form.
7.
This application MUST be filled out by the owner or a principle of the company.
8.
This application MUST be signed by the Head of the Fire Department in the city or town
where the Black or Smokeless Powder will be sold. (Section VI.)
9.
All applications must be submitted to the Office of the State Fire Marshal’s Office at least
30 days prior to expiration of your current license
.
II.
APPLICANT INFORMATION
Name of Applicant:
Date of Birth: _______________
(Last)
(First)
(Middle)
(Month)
(Day)
(Year)
Address:
Phone Number: _____________
City/Town, State, Zip: _____________________________________________________________
Mailing Address (
If Different): _____________________________________________________________________________________
P. O. Box or Street
City/Town, State, Zip
Social Security Number:
Are you a U.S. Citizen: { } YES { } NO
Email Address _____________________________________________________________
(All renewal notices will be sent electronically, not by regular mail, effective immediately.)
Height:
Weight:
Eyes:
Hair:
Sex: _________
Mail completed application to: Department of Fire Services • Attn: Licensing Desk
FP-081 Rev. 1/18
P.O. Box 1025, 1 State Road, Stow, MA 01775
Revenue Code 3090
978-567-3375 •
www.mass.gov/dfs
Application for License to Sell Black or Smokeless Powder (FP-081)
NEW ______
RENEWAL SP# ______
I.
APPLICATION INSTRUCTIONS
Follow the instructions below to complete the Application for a License to Sell Black or Smokeless Powder:
1.
Type or print in black ink all items on this form and sign the form in Section V.
2.
Include a notarized statement on company letterhead indicating that these explosive
materials shall be stored according to the requirements of 527 CMR 1.00.
3.
Include payment of $100.00 for a NEW license made payable to the Commonwealth of
Massachusetts. Include payment of $50.00 for a RENEWAL license made payable to the
Commonwealth of Massachusetts.
4.
Include a legible copy of your current driver’s license.
5.
If you sell Black Powder, include a legible copy of your current ATF Permit.
6.
Complete and have notarized the CORI request form.
7.
This application MUST be filled out by the owner or a principle of the company.
8.
This application MUST be signed by the Head of the Fire Department in the city or town
where the Black or Smokeless Powder will be sold. (Section VI.)
9.
All applications must be submitted to the Office of the State Fire Marshal’s Office at least
30 days prior to expiration of your current license
.
II.
APPLICANT INFORMATION
Name of Applicant:
Date of Birth: _______________
(Last)
(First)
(Middle)
(Month)
(Day)
(Year)
Address:
Phone Number: _____________
City/Town, State, Zip: _____________________________________________________________
Mailing Address (
If Different): _____________________________________________________________________________________
P. O. Box or Street
City/Town, State, Zip
Social Security Number:
Are you a U.S. Citizen: { } YES { } NO
Email Address _____________________________________________________________
(All renewal notices will be sent electronically, not by regular mail, effective immediately.)
Height:
Weight:
Eyes:
Hair:
Sex: _________
Mail completed application to: Department of Fire Services • Attn: Licensing Desk
FP-081 Rev. 1/18
P.O. Box 1025, 1 State Road, Stow, MA 01775
Revenue Code 3090
978-567-3375 •
www.mass.gov/dfs
III. LICENSE TO SELL BLACK OR SMOKELESS POWDER
Name of Firm or Corporation making application:____________________________________________________
Street Address:
Phone Number: _____________
Mailing Address (
:
If Different)
P. O. Box,/Street
City/Town, State, Zip: _____________________________________________________________
My current (if Renewal) MA License to Sell Black or Smokeless Powder expires on: ___________
Indicate whether or not you are selling Black Powder.
{ }YES { }NO
If yes, please include a legible copy of your current ATF Permit.
In accordance with Title 18, United States Code, Chapter 40, I possess a valid Federal
Explosive User Permit
{ }YES { }NO
My Federal Explosive User Permit Number is: ______________________________________
IV.
GENERAL
Have you ever been convicted in any state or federal court of a crime punishable by imprisonment
for a term exceeding one year? (Whether or not you actually served time)
{ }YES { }NO
Have you ever been admitted to any hospital or institution for mental illness?
{ }YES { }NO
Have you ever been convicted in any state or federal jurisdiction of any controlled substance law?
{ }YES { }NO
Have you ever been ordered by a court to receive treatment for drug or alcohol abuse?
{ }YES { }NO
Have you ever had a license, permit or right to use explosives suspended or revoked in any
state or federal jurisdiction?
{ }YES { }NO
Are you currently taking any medication which may impair your ability to safely conduct
a licensed activity?
{ }YES { }NO
Have you ever been involved in any incident(s) resulting from the use of explosives which
resulted in personal injury or property damage?
{ }YES { }NO
All questions must be answered.
Any question answered “Yes” must be explained on an attached sheet of paper.
Mail completed application to: Department of Fire Services • Attn: Licensing Desk
Department of Fire Services • P.O. Box 1025, 1 State Road, Stow, MA 01775
FP-081 Rev. 1/18
978-567-3375 •
www.mass.gov/dfs
Revenue Code 3090
V.
APPLICANT CERTIFICATION
I attest that I have reviewed and am familiar with all Commonwealth of Massachusetts Explosives Laws
and Regulations, and all federal laws and regulations relative to the transportation, possession and use
of explosive materials. I hereby consent to the release of all personal records containing data relative
to this application, maintained by any individual or agency. I certify that I am authorized to execute this
application.
PURSUANT TO MASSACHUSETTS GENERAL LAWS, CHAPTER 62C, SECTION 49A, I CERTIFY UNDER THE PENALTIES
OF PERJURY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, I HAVE FILED ALL STATE TAX RETURNS AND PAID
ALL STATE TAXES REQUIRED UNDER LAW.
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.
Signature:
Date:
_____________
VI.
FIRE DEPARTMENT ENDORSEMENT
Applicant has met all local licensing and permitting requirements for the storage and sale of Black or Smokeless Powder:
Head of Fire Department: (Please Print)_______________________ Signature: ________________________________
Date: ___________________________________
Mail completed application to: Department of Fire Services • Attn: Licensing Desk
Department of Fire Services • P.O. Box 1025, 1 State Road, Stow, MA 01775
FP-081 Rev. 1/18
978-567-3375 •
www.mass.gov/dfs
Revenue Code 3090
CORI REQUEST FORM
The Department of Fire Services, Office of the State Fire Marshal (Agency #820), has been certified by the
Criminal History Systems Board for access to general use/CJIS records:
Applicant/Employee Information
(Please Print)
_______________________________________________________________________________________________
Last Name
First Name
Middle Name
___________________________________
___________________________________________
Maiden Name or Alias (if applicable)
Place of Birth
________________
_________________________
___________________________________________
Date of Birth
Social Security Number
Mother’s Maiden Name
(requested but not required)
Former Residential Addresses:
Sex: _____
Height: ___ ft. ____ in.
Weight: _____
Eye Color: __________ Hair Color:
____________
Drivers License: State
________
Number:
_______________________________________________________
Applicant Signature:
Statement of Notary Public:
The above information was verified by reviewing the following form of government issued photographic identification:
ss:
Date:
_______
Before me, then personally appeared the above named Affiant,
who acknowledged, by his signature, the foregoing Affidavit and Endorsement to be true and to be the Affiant’s free
act and deed.
Notary Signature:
Notary Name (printed):
Commission Expiration Date:
(Seal)
Requested By:
Signature of CORI Authorized Employee
(MA State Police Assigned)
Mail completed application to: Department of Fire Services • Attn: Licensing Desk
Department of Fire Services • P.O. Box 1025, 1 State Road, Stow, MA 01775
FP-081 Rev. 1/18
978-567-3375 •
www.mass.gov/dfs
Revenue Code 3090
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