2. OFFICE OF THE TOWNSHIP CLERK

   95 West Veterans Highway

   Jackson, NJ 08527

   (732) 928-1200 ext. 1200-1201 | Fax (732)928-4377

4. RETAIL FOOD LICENSE APPLICATION

8. *RETAIL FOOD LICENSES ARE VALID UNTIL DECEMBER 31 AND MUST BE RENEWED ANNUALLY*

10. Retail Food, Floor Plan Review
    Food Plan Guideline
12. Application is hereby made to the Board of Health and to Jackson Township for a license to operate a Business.
14. Name of Establishment
16. Address of Establishment
18. If granted, this license is to be issued in the name of
20. Corporation Name:
22. Address of Applicant:
24. City
25. State
26. Zip Code
28. Business Number
29. Cell Number
30. Email Address
32. Does this establishment provide catering or delivery?
33. Are foods prepared at another location?

    1. YES

    1. NO
35. If YES, please provide name and address of the location below.
37. If establishment is owned by an out of state owner or corporation, please provide name and address of regional office, name of contact person, telephone number and email address:

39. Please provide the following certificate information:

41. Upload Certificate of Liability Insurance*
43. Copy of Ocean County Health Department “Satisfactory” certificate*
45. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
48. Date:
    Date:

50. Do Not Complete Below

    ***************************************************************************************

    HEALTH OFFICER’S INSPECTION REPORT
    Inspection of the above premises was completed on _____________________ and it is recommended that
    The licensed BE______ NOT BE_____ issued. If recommendation is for non-issuance, attach inspection report. 

                                                                                                       ___________________________________
                                                                                                                                     HEALTH OFFICER 
    
    

52. Date Payment Received ($20.00- annual fee):
53. Payment type:

    1. Cash

    1. Check

55. In person or by mail: 95 West Veterans Highway, Jackson, NJ, 08527
    

Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

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