Registration

Owner Information

Today's Date

Owner Name

First Name

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Last Name

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Contact Information

Primary Phone

Please enter a mobile number in the following format: XXX-XXX-XXXX

Primary Email

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Home Street Address

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Home Street Address 2

Home Town

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Home State

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Home Zip Code

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Is your mailing address different than your property address?

Business Registration

Business Address

Entity name

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Business Information

Business Name

Please enter your business' name

Business Type

Please select your business' type

Position/Title

Business Phone

Business Type (Please select all that apply)

Business Fee

Business Contact Information

Contact Name

First Name

Please enter the first name of the primary contact for your business

Last Name

Please enter the last name of the primary contact for your business

Contact Email

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Contact Phone

Primary Phone

Please enter a work number in the following format: XXX-XXX-XXXX

Secondary Phone

Contact Address

Contact Secondary Address

Contact City

Contact State

Contact Zip Code

Food Establishment Information

Establishment Trade name

Please enter your establishment's trade name

Establishment Address

Contact Information

Phone #

Please enter your establishment's phone number

Fax #

Please enter your establishment's fax number

Manager or Person in Charge

Please enter the establishment's manager's name

Certified Food Handler

Please enter the establishment's certified food handler

Hours of Operation & SQ footage

Hours of Operation

Please enter the establishment's hours of operation

SQ footage

Please enter the establishment's square footage

Emergency Contact (to be used in case of an after-hours emergency)

Name

Please enter the establishment's emergency contact's name

Phone #

Please enter the establishment's emergency contact's phone #.

Grease Hauler

Grease Hauler Name

Please enter the Grease Hauler's name

Grease Hauler Phone #

Please enter the Grease Hauler's phone #

Garbage Hauler

Garbage Hauler Name

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Garbage Hauler Phone #

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Recycling Hauler

Recycling Hauler Name

Please enter the Recycling Hauler's name

Recycling Hauler Phone #

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Exterminator

Exterminator Name

Please enter the Exterminator's name

Exterminator Phone #

Please enter the Exterminator's phone #

Mail License To

Please select a location

Please enter your full name to hereby apply for a license to operate a retail food establishment and agree to comply with, and abide by, all the provisions of N.J.A.C. 8:24 of the New Jersey Sanitary Code and all local codes regulating retail food establishments. You further understand that this license is not transferable and may be revoked upon violation of these codes.

As per N.J.A.C. 8:24, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines,Section 8.6 Emergency Occurrences indicates the following: The operator or person in charge shall immediately take necessary remedial action and notify the health authority if an imminent health hazard may exist because of an emergency such as a fire, flood, extended interruption of electrical or water service, sewage backup, misuse of poisonous or toxic materials, onset of an apparent foodborne illness outbreak, gross insanitary occurrence or condition, or other circumstance that may endanger public health, except that the person in charge need not discontinue operations in an area of the establishment that is unaffected by the imminent health hazard.

In the event of an imminent health hazard involving any situation related to 8:24-8.6, the Permit / License holder shall:

1. Assess the situation. Immediately discontinue operation if a safe operation cannot be maintained using an alternative procedure.

2. Notify the Somerset County Department Health (SCDOH) of the imminent health hazard and discuss if alternative procedures can be used. Emergency Procedures Action Planning Guidance can be found at the following link: http://www.state.nj.us/health/foodanddrugsafety/documents/emergency_actionplans.pdf

3. Follow the appropriate emergency procedures if approved by the SCDOH or remain closed until granted approval to re-open by the SCDOH.

If a Retail Food Establishment is found to be operating during an emergency occurrence, a summons will be issued to the Establishment and a fine imposed.

Please enter your full name to hereby acknowledge and agree to comply with, and abide by the above stated procedures and all the provisions of N.J.A.C. 8:24 of the New Jersey Sanitary Code and all local codes regulating retail food establishments

Subtotal
Convenience Fee	TBD by payment type

Owner Information

Today's Date

Owner Name

Contact Information

Home Street Address

Home Street Address 2

Home Town

Home State

Home Zip Code

Mailing Address

Mailing Address 2

Mailing Town

Mailing State

Mailing Zipcode

Business Registration

Business Address

Entity name

Business Information

U.S. Citizen?

Driver's License #

Birthplace

Length of Residence in NJ

Previous Address

Position/Title

Business Phone

Business Type (Please select all that apply)

Number of Coin Operated Ice Machines (If none then please enter 0)

Number of Games License Pool Tables (If none then please enter 0)

Number of Pool Tables (If none then please enter 0)

Number of Taxi Operator Renew (If none then please enter 0)

Business Fee

Business Contact Information

Contact Name

Contact Email

Contact Phone

Contact Address

Contact Secondary Address

Contact City

Contact State

Contact Zip Code

Food Establishment Information

Establishment Trade name

Establishment Address

Contact Information

Manager or Person in Charge

Certified Food Handler

Hours of Operation & SQ footage

Emergency Contact (to be used in case of an after-hours emergency)

Grease Hauler

Garbage Hauler

Recycling Hauler

Exterminator

Mail License To

Please enter your full name to hereby acknowledge and agree to comply with, and abide by the above stated procedures and all the provisions of N.J.A.C. 8:24 of the New Jersey Sanitary Code and all local codes regulating retail food establishments

Review and Submit

Payment Type

Total Fee

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Payment Information

Business License Information