Form F-41 "Renewal Application to Operate a Wholesale Food/Cosmetic Establishment" - New Jersey

What Is Form F-41?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form F-41 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form F-41 "Renewal Application to Operate a Wholesale Food/Cosmetic Establishment" - New Jersey

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New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check/Money Order No.:
PO Box 369
Trenton, NJ 08625-0369
Check/MO Date:
Phone: 609-826-4935
Amount:
RENEWAL APPLICATION TO OPERATE A
Logger Initials:
WHOLESALE FOOD / COSMETIC ESTABLISHMENT
PURSUANT TO N.J.A.C. 8:21-9-4(a)
LICENSE/PERMIT NUMBER:
FOR THE PERIOD ENDING:
LOCATED AT:
Failure to apply for renewal may subject you to penalty as provided by law. Expiration date appears on license.
Please provide all information requested. If you have discontinued operations, complete last section only and
return to above address. TYPE OR PRINT WITH BALL POINT PEN.
REASONS FOR CORRECTIONS:
If Name or Address is incorrect, make necessary corrections below.
Change in Trade Name
Change in Corporate Structure
Change in Location
Change in Mailing Address
Change in Ownership
Phone Number:
Fax Number:
Email Address:
Federal ID #/SSN:
MAKE CHECK OR MONEY ORDER PAYABLE TO: “TREASURER, STATE OF NEW JERSEY.”
INDICATE ANNUAL GROSS WHOLESALE BUSINESS, BASED ON YOUR LAST FISCAL YEAR
ANNUAL FEE
1. Less than $100,000.00 ........................................................................................................................$150.00
2. In excess of $100,000.00, but not in excess of $500,000.00..............................................................$500.00
3. In excess of $500,000.00 .................................................................................................................$1,000.00
CORPORATE OFFICER INFORMATION
Name of President (Print)
Name of Secretary (Print)
Name of Vice-President (Print)
Name of Treasurer (Print)
AFFIDAVIT
State of ____________________________
County of ___________________________
I, ____________________________________________, being duly sworn according to law upon his(her) oath deposes and
says that he(she) is (President, Vice President, Secretary, Treasurer, Owner) and hereby certifies that the information given in
this application is true and complete to the best of his(her) knowledge, information and belief.
Sworn and Subscribed before me this ____________ day
___________________________________________
Signature and Title of Applicant
of _______________________, in the year ___________.
______________________________________________
_______________________________
Notary Public Signature
Date
DISCONTINUANCE OF OPERATIONS INFORMATION
Date Operations Discontinued
Name of Purchaser
Date Sold
Address of Purchaser
Signature of Former Operator
Address of Former Operator
F-41
AUG 13
New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check/Money Order No.:
PO Box 369
Trenton, NJ 08625-0369
Check/MO Date:
Phone: 609-826-4935
Amount:
RENEWAL APPLICATION TO OPERATE A
Logger Initials:
WHOLESALE FOOD / COSMETIC ESTABLISHMENT
PURSUANT TO N.J.A.C. 8:21-9-4(a)
LICENSE/PERMIT NUMBER:
FOR THE PERIOD ENDING:
LOCATED AT:
Failure to apply for renewal may subject you to penalty as provided by law. Expiration date appears on license.
Please provide all information requested. If you have discontinued operations, complete last section only and
return to above address. TYPE OR PRINT WITH BALL POINT PEN.
REASONS FOR CORRECTIONS:
If Name or Address is incorrect, make necessary corrections below.
Change in Trade Name
Change in Corporate Structure
Change in Location
Change in Mailing Address
Change in Ownership
Phone Number:
Fax Number:
Email Address:
Federal ID #/SSN:
MAKE CHECK OR MONEY ORDER PAYABLE TO: “TREASURER, STATE OF NEW JERSEY.”
INDICATE ANNUAL GROSS WHOLESALE BUSINESS, BASED ON YOUR LAST FISCAL YEAR
ANNUAL FEE
1. Less than $100,000.00 ........................................................................................................................$150.00
2. In excess of $100,000.00, but not in excess of $500,000.00..............................................................$500.00
3. In excess of $500,000.00 .................................................................................................................$1,000.00
CORPORATE OFFICER INFORMATION
Name of President (Print)
Name of Secretary (Print)
Name of Vice-President (Print)
Name of Treasurer (Print)
AFFIDAVIT
State of ____________________________
County of ___________________________
I, ____________________________________________, being duly sworn according to law upon his(her) oath deposes and
says that he(she) is (President, Vice President, Secretary, Treasurer, Owner) and hereby certifies that the information given in
this application is true and complete to the best of his(her) knowledge, information and belief.
Sworn and Subscribed before me this ____________ day
___________________________________________
Signature and Title of Applicant
of _______________________, in the year ___________.
______________________________________________
_______________________________
Notary Public Signature
Date
DISCONTINUANCE OF OPERATIONS INFORMATION
Date Operations Discontinued
Name of Purchaser
Date Sold
Address of Purchaser
Signature of Former Operator
Address of Former Operator
F-41
AUG 13