TOWNSHIP OF MENDHAM - BOARD OF HEALTH

APPLICATION FOR RETAIL FOOD ESTABLISHMENT LICENSE

DATE__________________

ESTABLISHMENT NAME_____________________________________________________

ADDRESS

_______________________________________________________

                        MAILING ADDRESS ______________________________________________
                                          _______________________________________________________

                         TELEPHONE____________________________________________________

OWNER NAME_______________________________________________________________

                           ADDRESS______________________________________________________

_______________________________________________________

                          TELEPHONE____________________________________________________

MANAGER OR PERSON IN CHARGE____________________________________________

BRIEF DESCRIPTION OF THE BUSINESS_________________________________________

_______________________________________________________________________

I, ______________________________, hereby apply for a license to operate a food establishment and agree to comply with, and abide by, all the provisions of Chapter 12 of the New Jersey Sanitary Code and all local codes regulating retail food establishments.

                                    SIGNED________________________________________________

MAKE CHECKS PAYABLE TO THE TOWNSHIP OF MENDHAM

REGULAR LICENSE - $220.00

TEMPORARY LICENSE  (14 days) - $30.00

EXEMPT