STATE OF MISSISSIPPI
DEPARTMENT OF AGRICULTURE AND COMMERCE
ANDY GIPSON
COMMISSIONER
P. O. BOX 1609 ∙ JACKSON, MISSISSIPPI 39215 ∙ www.mdac.ms.gov ∙ TELEPHONE (601) 359-1148
EQUAL OPPORTUNITY IN EMPLOYMENT AND SERVICES
RE: Mississippi Retail Food Establishments
Mobile Retail Food Establishment License
§ 69-1-18. Definitions; authority of commissioner to promulgate rules and regulations and
to conduct sanitation inspections in retail food stores; licensing; penalties
(3) Each retail food establishment, before engaging in business, shall obtain a license from the
commissioner. Owners of more than one (1) retail food establishment must obtain a license for
each establishment. A license fee of Ten Dollars ($10.00) must be paid to the department before a
license will be issued. Application for such license shall be made on forms prescribed and
furnished by the commissioner. Licenses issued under this subsection by the commissioner shall
expire on June 30 each year and application for renewals thereof shall be made annually before
the expiration date. Licenses shall not be transferable and application must be made for a new
license if there is any change in location or ownership of the business.
Applications should be completed and mailed along with a check or money order payable to the
MDAC, Consumer Protection Division, P. O. Box 1609, Jackson, MS 39215-1609. After the
application has been processed a license will be issued.
The Department has implemented an online renewal system; however, first time applicants
must receive a Business ID before the online system can be used. To renew your license,
please visit www.ms.gov/mdac/retail_food.
Please note if your store is a small store, such as a convenience store that has recently started
cooking, it may now be regulated by the Mississippi State Department of Health.
For questions about licensing, laws, regulations, or policy, please call please call the Consumer
Protection office at 601-359-1148.
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Mississippi Department o
f Agriculture and Commerce
Consumer Protection Division
Henri Fuselier, Jr., Director
P O Box 1609 ~ Jackson, Mississippi 39215 ~ (601) 359-1148 Fax: (601) 359-1175
ID No. _________________
APPLICATION FOR MOBILE RETAIL FOOD ESTABLISHMENT LICENSE
The undersigned applicant hereby applies for a license to engage in business as a Mobile Retail Food Establishment, as required by
Miss. Code Ann. §69-1-18.
CHECK ONE: ( ) New ( ) Renewal
If Renewal, has there been a change of ownership since last retail food sanitation license? ( ) YES ( ) NO
“New” means you did not have a vehicle licensed with us last year. Your vehicle will require an inspection before a license is granted; “Renewal”
means your vehicle did have a license with us last year.
Full Name of Mobile Retail Establishment (As Filed with the Secretary of State)
Current License Number:
Physical Address: City: State: Zip:
Mailing Address if Different from above: City: State: Zip:
Telephone No.
E-mail Address, Fax Number:
County
Registered Legal Agent Representing this Business (As Filed with the Secretary of State)
Registered Agent Address
Employer ID Number (Federal Tax ID Number)
(IF SSN, LEAVE BLANK)
TYPE OF OWNERSHIP: ( ) Individual ( ) Partnership ( ) LLC ( ) Corporation
Name of Owner/Partner/Manager
If Corporation: In what state incorporated:
Corporation phone No.:
Principal office in State of Mississippi or resident agent:
If Partnership, List Partners:
If Partnership, Address of Partners:
Mobile Unit Vehicle Information:
* Vehicle Tag Number/s _______________________________________________________________________________________
* Vehicle Number/s [if applicable] _______________________________________________________________________________
* MS Tax I.D. Number_________________________________________________________________________________________
*Counties in Mississippi where sales will be conducted _______________________________________________________________
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The undersigned applicant hereby certifies that all statements, information, or schedules attached hereto are true and correct
and applicant will comply with the Mississippi Retail Food Sanitation Law and Regulations and allow access to the
establishment for inspection by the regulatory agency during the food establishment’s hours of operation and other reasonable
times.
This the __________ day of ____________________, 20__________
______________________________________
Full name of applicant (Print Name)
______________________________________
Applicant’s Signature
__________________________________________
Title
__________________________________________
Firm name (If corporation)
NOTE: (1.) Application must be signed. If partnership, each partner must sign. If corporation, corporate name must be
signed in full with the officer’s name or name of agent authorized to sign the application and title.
(Office Use Only)
Do Not Write Below
ATTENTION:
This completed application and a check or money
order, in the amount of $10.00, for each vehicle,
payable to the Mississippi Department of Agriculture
and Commerce, should be mailed to the address
indicated at the top of the front page of this
application. Applications that are incomplete and/or
the fee is not submitted will not be processed.
(Date Received)
Check Number_____________________________
Amount Received___________________________
