Application for a License

Mammography facilities shall apply for a license to operate the facility issued pursuant to M.G.L. c. 111 § 5Q. (A) Applications for licensure shall be made on forms prescribed by and available from the Department. Each applicant shall submit all the information required by the form and the accompanying instructions. The term "application" as used herein shall include original and renewal applications. (B) The applicant shall provide at least the following information in order to be issued a license to operate a mammography facility: (1) Name, address and telephone number of the following: (a) The mammography facility; and, (b) The prospective licensee of the mammography facility, including a statement of ownership of the facility that discloses the name and addresses of all owners or in the case of a corporation, the officers; (2) The manufacturer, model number, model year, serial number (if available) and type of each mammography machine located within the facility; (3) The geographic areas to be serviced, if the facility is mobile; The name and address of the mammography machine supplier, installer, date of installation of each mammography machine, and service agent; and (5) A signed and dated certification that the applicant has read, understood, and complies with the requirements of 105 CMR 127.000. (C) Each applicant shall provide such additional information as the Department may reasonably require. (D) Each applicant shall submit with his or her application for a license a check payable to the Commonwealth of Massachusetts. The fee for a license is specified in 801 CMR 4.00: Rates.