Form CPIP-06 "Application for Registration of Item Price Exemption" - Connecticut

What Is Form CPIP-06?

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

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Connecticut State Department of Consumer Protection;
  • 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 fillable version of Form CPIP-06 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Consumer Protection.

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Download Form CPIP-06 "Application for Registration of Item Price Exemption" - Connecticut

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For Official Use Only
CPIP-06, REV 7/17
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
FOOD & STANDARDS DIVISION
Telephone: (860) 713-6160
Web Site:
www.ct.gov/dcp
Email: food.standards@ct.gov
APPLICATION FOR REGISTRATION OF ITEM PRICE EXEMPTION
INSTRUCTIONS
All spaces must be completed - please print in ink or type. This application must be accompanied by a
check or money order for each location made payable to: "Treasurer, State of Connecticut."
$315.00
, if the premises consists of less than twenty thousand (20,000) square
feet of retail space, or,
$625.00
,
if the premises consists of or is greater than twenty thousand
(20,000) square feet of retail space.
Return your completed application and fee to:
Department of Consumer Protection, License Services Division,
450 Columbus Blvd., Suite 801, Hartford, CT 06103
Name of Business (DBA)
Street Address
City
State
Zip Code
Name of Parent Company (Corporation, Partnership, LLC, etc.)
Telephone Number (w/area code)
Federal ID Number
Name of Principal Officer in Charge
Street Address & Town Where Exemption is being sought
(1) The retailer understands that for each location for which an exemption from individually pricing of each consumer commodity
issought , the retailer must demonstrate to the satisfaction of the Commissioner that the retailer has achieved price scanner accuracy
of atleast ninety-eight per cent, as determined by the latest version of the National Institute of Standards and Technology Handbook
130,"Examination Procedures for Price Verification, as adopted by The National Conference on Weights and Measures,"(2) The
retailer pays an application fee, to be used to offset annual inspection costs, of two hundred fifty dollars if the premises consistsof
less than twenty thousand square feet of retail space and five hundred dollars if the premises consists of twenty thousand square feet
ormore of retail space,(3) The retailer makes available a consumer price test scanner approved by the commissioner and located
prominently in an easilyaccessible location for each twelve thousand square feet of retail floor space, or fraction thereof, and,(4)
Price accuracy inspections resulting in less than ninety-eight per cent price scanner accuracy are reinspected once without penalty
andthe retailer pays a two hundred dollar reinspection fee.(5) A conspicuous sign shall adequately disclose to the consumer that in
the event the electronic price is higher than the posted retailprice, one item of such consumer commodity up to a value of $20.00
shall be given to the customer at no cost.
I certify that I am duly authorized to exercise principal authority in the State of Connecticut on behalf of the above applicant.I
also subscribe and affirm under penalties of perjury, that the statements made in this application have been examined byme
and to the best of my knowledge and belief are true and correct. I have been advised that any statement(s) made hereinwhich
I do not believe to be true and which is intended to mislead a public servant acting in an official manner is a crimeunder C.G.S.
Section 53a-157.
______________________________________________________________
______________________________
Signature of Duly Authorized Applicant
Date
For Official Use Only
CPIP-06, REV 7/17
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
FOOD & STANDARDS DIVISION
Telephone: (860) 713-6160
Web Site:
www.ct.gov/dcp
Email: food.standards@ct.gov
APPLICATION FOR REGISTRATION OF ITEM PRICE EXEMPTION
INSTRUCTIONS
All spaces must be completed - please print in ink or type. This application must be accompanied by a
check or money order for each location made payable to: "Treasurer, State of Connecticut."
$315.00
, if the premises consists of less than twenty thousand (20,000) square
feet of retail space, or,
$625.00
,
if the premises consists of or is greater than twenty thousand
(20,000) square feet of retail space.
Return your completed application and fee to:
Department of Consumer Protection, License Services Division,
450 Columbus Blvd., Suite 801, Hartford, CT 06103
Name of Business (DBA)
Street Address
City
State
Zip Code
Name of Parent Company (Corporation, Partnership, LLC, etc.)
Telephone Number (w/area code)
Federal ID Number
Name of Principal Officer in Charge
Street Address & Town Where Exemption is being sought
(1) The retailer understands that for each location for which an exemption from individually pricing of each consumer commodity
issought , the retailer must demonstrate to the satisfaction of the Commissioner that the retailer has achieved price scanner accuracy
of atleast ninety-eight per cent, as determined by the latest version of the National Institute of Standards and Technology Handbook
130,"Examination Procedures for Price Verification, as adopted by The National Conference on Weights and Measures,"(2) The
retailer pays an application fee, to be used to offset annual inspection costs, of two hundred fifty dollars if the premises consistsof
less than twenty thousand square feet of retail space and five hundred dollars if the premises consists of twenty thousand square feet
ormore of retail space,(3) The retailer makes available a consumer price test scanner approved by the commissioner and located
prominently in an easilyaccessible location for each twelve thousand square feet of retail floor space, or fraction thereof, and,(4)
Price accuracy inspections resulting in less than ninety-eight per cent price scanner accuracy are reinspected once without penalty
andthe retailer pays a two hundred dollar reinspection fee.(5) A conspicuous sign shall adequately disclose to the consumer that in
the event the electronic price is higher than the posted retailprice, one item of such consumer commodity up to a value of $20.00
shall be given to the customer at no cost.
I certify that I am duly authorized to exercise principal authority in the State of Connecticut on behalf of the above applicant.I
also subscribe and affirm under penalties of perjury, that the statements made in this application have been examined byme
and to the best of my knowledge and belief are true and correct. I have been advised that any statement(s) made hereinwhich
I do not believe to be true and which is intended to mislead a public servant acting in an official manner is a crimeunder C.G.S.
Section 53a-157.
______________________________________________________________
______________________________
Signature of Duly Authorized Applicant
Date
Additional Instructions:
1. Please submit a plan for implementation including copies of shelf labels, indicating item and unit price and
specifications for the consumer price test scanner, see item #3 above, with this application for review and
approval.
2. Conspicuous sign means a sign attached to the cash register/checkout terminal which shall be at least six
inches by nine inches in size, easily readable by a consumer making a purchase at such cash register/checkout
terminal, and shall not contain any additional text. As an alternative to such cash register/checkout terminal
signs, the retailer may display a conspicuous sign, with minimum dimensions of 22 inches by 28 inches, at
each public entrance within the store which sign shall not contain any store or promotional slogans, names, or
advertising and which shall read as follows: "In the event that a consumer commodity, scans at an incorrect
higher price, you will be given one item of that consumer commodity free of charge up to a value of
$20.00,credit will be given for items of higher value."
FOR OFFICIAL USE ONLY
:
:
:
:
INSPECTION DATE
INSPECTED BY
APPROVED BY
APPROVAL DATE
:
:
:
#:
FEE DUE
LATE FEE
FEE COLLECTED
CHECK OR MONEY ORDER
#
:
NEW
RENEWAL
CURRENT REGISTRATION
EXPIRATION DATE
LICENSE
APPLICATION
ONE TIME FEE
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