New Renewal

Bakery Bar Deli Eat In Restaurant Grocery Store Hospital Liquor Store Meat Distributor Meat Manufacturer Milk Distributor Mobile Unit Other Pharmacy Prepackaged Foods School Sidewalk Cafe Supermarket Take Out Restaurant Vending Machine

Yes No

Restaurant Coffee Shop Luncheonette Sandwich Shop Class A Tavern/Rest.

Private Public

AL AK AZ AR CA CO CT DE FL HI ID IL IA KS KY ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS DC FM GU MH MP PW PR VI

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Yes No

Yes No

Yes No

Yes No

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Yes No

Phone # *

ZIP *

City *

Address *

If "Yes," specify Seating Capacity

Block

State *

Food Court *

Business Details

Registration Type *

Please add Business Owner information, not Building Owner.

2nd Last Name

Phone # *

Poultry Slaughter House *

First Name *

If food or beverage is consumed on the premises (except Sidewalk Cafe):

Address 2

Property

Food Service Locations

Day Care Facilities *

If business category is Sidewalk Cafe, answer the following:

Name *

Pharmacies *

If "Other" specify

Nursing Homes *

Lot

2nd First Name

Meat Establishments *

Operator Name

Do you have designated seating capacity?

Milk License *

Federal ID # *

Florist *

Business Category *

Business Owner Details

Church and School Kitchens *

Address

Licenses Required

Prepackaged License *

Email *

Description *

Vending Machine License *

Festival *

Seating Capacity

If "No" provide Square Footage

Email *

Last Name *

Business

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

How many Women's

State Milk License #

How many Food Handlers Employed *

Do you have Public Bathrooms? *

Do you sell milk? *

Do you have the "Alcohol and Pregnancy" warning posted? *

Do you have a Certified Food Manager? *

How many Men's

Food Establishment

If yes, how many?

State Milk License Expiration Date

Do you have a Liquor License? *

Do you have a Dance Hall? *

Do you have "No Smoking" and "Exit" Signs posted? *

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Food Suppliers

City, State, ZIP

Potable water supplied according to regulations and stored and handled in a sanitary manner and protected from contamination.

Separate area for loading and unloading food and/or related supplies.

Cleaning Service

List vehicle(s) type, make and model

Liquid wastes of retention tanks from mobile units connected to and discharging to a sanitary sewerage disposal system conforming with the Standards for the Construction of Individual Subsurface Sewage Disposal Systems and the N.J. Water Pollution Control Act Regulations and Local Laws, Ordinances and Regulations.

List supplier(s) name and address

Location for flushing drainage of liquid wastes.
(Drains comply with State and Local Plumbing Regulations.)

Services Provided: *

Surface area constructed of concrete or machine-laid asphalt or a smooth non-absorbent material... maintained in good repair, clean and graded to drain.

Other services provided:

Overhead protection for any supplying, cleaning or servicing operation.

Explain, type of procedure to sanitize food contact surfaces and sketch of area where this will be provided:

Separate for providing potable water servicing.

Cleaning Establishment Address

List machine(s) and locations by address and the make and description of each machine therein

Address of each commissary and other establishment where supplies for such machine(s) are kept and where such vending machines are repaired or renovated

List applicant(s) and their titles

Food Vending Machine

* Important: Proof of Business Liability Insurance, valid State Milk License and current Tax ID must be attached in order to process your application.

Poultry Slaughter House

Total Vehicle

Business
(Square Feet)

Day Care Facilities

Seating Capacity

Milk License

Vending Machine License

Festival

Prepackaged License

Sidewalk Cafe Seating Capacity Fee

Total Food Supplier

Total Vending Machine

Fee Schedule

Food Court

Amount Due

Pharmacies

Certification

Required Documents

Applicant Signature

Nursing Homes

Church and School Kitchens

Florist

Meat Establishment