Form F-29 "Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment" - New Jersey

What Is Form F-29?

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 July 1, 2012;
  • 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;
  • Fill out the form in our online filing application.

Download a printable version of Form F-29 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-29 "Initial Application for License to Operate a Wholesale Food-Cosmetic Establishment" - New Jersey

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New Jersey Department of Health
STATE USE ONLY
Consumer, Environmental and Occupational Health Service
PO Box 369, Trenton, NJ 08625-0369
Phone: 609-826-4935
Fax: 609-826-4990
www.nj.gov/health/foodanddrugsafety
INITIAL APPLICATION FOR LICENSE TO OPERATE
A WHOLESALE FOOD-COSMETIC ESTABLISHMENT (N.J.S.A. 24:15-14)
Complete all information. Indicate gross annual dollar volume of business based on your last fiscal year. If new business, estimate
dollar volume for current fiscal year. Mail original copy with your fee to the above address. Retain a copy for your records.
Annual Gross Wholesale Business (check applicable box)
Annual Fee
MAKE CHECK OR MONEY ORDER
Less than $100,000.00 .................................................................... $150.00
PAYABLE TO:
Excess of $100,000.00, but not in excess of $500,000.00 .............. $500.00
“New Jersey Department of Health”
In excess of $500,000.00.............................................................. $1,000.00
Check/Money Order No.
Date of Check/Money Order
Amount
Date of Application
IDENTIFICATION
Name of Owner or Corp.
Establishment Location
Trade Name
City
State
Zip Code
Mailing Address
County Registered
City
State
Zip Code
Telephone Number
Fax Number
If Incorporated, Name of State
Federal ID/Social Security No.
Email Address
FOOD
COSMETICS
Manufacturer
Repacker
Manufacturer
Repacker
Wholesale Distributor
Other
Wholesale Distributor
Other
Warehouse
Warehouse
NAMES AND ADDRESSES OF OFFICERS
President (Full Name)
Address
City
State
Zip Code
Vice-President (Full Name)
Address
City
State
Zip Code
Secretary (Full Name)
Address
City
State
Zip Code
Treasurer (Full Name)
Address
City
State
Zip Code
New Jersey Registered Agent (If Applicable)
Address
City
State
Zip Code
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
F-29
JUL 12
Page 1 of 2 Pages.
New Jersey Department of Health
STATE USE ONLY
Consumer, Environmental and Occupational Health Service
PO Box 369, Trenton, NJ 08625-0369
Phone: 609-826-4935
Fax: 609-826-4990
www.nj.gov/health/foodanddrugsafety
INITIAL APPLICATION FOR LICENSE TO OPERATE
A WHOLESALE FOOD-COSMETIC ESTABLISHMENT (N.J.S.A. 24:15-14)
Complete all information. Indicate gross annual dollar volume of business based on your last fiscal year. If new business, estimate
dollar volume for current fiscal year. Mail original copy with your fee to the above address. Retain a copy for your records.
Annual Gross Wholesale Business (check applicable box)
Annual Fee
MAKE CHECK OR MONEY ORDER
Less than $100,000.00 .................................................................... $150.00
PAYABLE TO:
Excess of $100,000.00, but not in excess of $500,000.00 .............. $500.00
“New Jersey Department of Health”
In excess of $500,000.00.............................................................. $1,000.00
Check/Money Order No.
Date of Check/Money Order
Amount
Date of Application
IDENTIFICATION
Name of Owner or Corp.
Establishment Location
Trade Name
City
State
Zip Code
Mailing Address
County Registered
City
State
Zip Code
Telephone Number
Fax Number
If Incorporated, Name of State
Federal ID/Social Security No.
Email Address
FOOD
COSMETICS
Manufacturer
Repacker
Manufacturer
Repacker
Wholesale Distributor
Other
Wholesale Distributor
Other
Warehouse
Warehouse
NAMES AND ADDRESSES OF OFFICERS
President (Full Name)
Address
City
State
Zip Code
Vice-President (Full Name)
Address
City
State
Zip Code
Secretary (Full Name)
Address
City
State
Zip Code
Treasurer (Full Name)
Address
City
State
Zip Code
New Jersey Registered Agent (If Applicable)
Address
City
State
Zip Code
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
F-29
JUL 12
Page 1 of 2 Pages.
INITIAL APPLICATION FOR LICENSE TO OPERATE A WHOLESALE FOOD-COSMETIC ESTABLISHMENT
SUPPLEMENTAL INFORMATION
Firm Name / Trade Name
Size of Building(s)
Sq. Ft.
Days of Operation (Days of Week)
Hours of Operation
to
AM
to
PM
Full Name of Contact Person
Telephone Number
Cell Phone Number
(
)
(
)
1.
Does your firm manufacture, distribute, repack, refill and/or label food and/or
2.
Do you handle seafood or shellfish at this
cosmetics?
location?
Food
Cosmetics
Both
Yes
No
3.
Category(ies) that best describe your operation (Check all that apply):
Manufacturer
Public/Company Warehouse
Repack/Refill
Bottling/Non-Alcoholic Beverages
Distributor
Refrigerated Warehouse
Label
4.
Briefly describe, in your own words, the process of your operation at this location (attach an additional sheet, if needed):
6.
Do you repack, refill, and/or label any products?
5.
Are any products stored at or below 45° F for more than 30
days?
Yes
No
Yes
No
If Yes, list the products below (attach an additional sheet, if
needed):
7.
List the products that your firm manufacturers (attach a product
list instead, if available):
8.
What is the reason for this new license application? (Check all that apply):
New Establishment
Moved to New Location
Change of Ownership
Inspector Information that License is Required
9.
If the business has been previously licensed by the New Jersey Department of Health, list the license number(s) or Firm Name/Trade
Name:
A.
B.
10. If you checked “Moved to New Location” in Question 8 above, provide the following information:
Previous License Number:
Previous Owner Name/Trade Name:
Previous Location Address:
Date of Inspection:
Name of Inspector:
11. List all related Food/Cosmetic firms that share your corporate name in New Jersey (attach an additional sheet, if needed):
A.
Owner Name:
Trade Name:
Location Address:
City:
Zip Code:
B.
Owner Name:
Trade Name:
Location Address:
City:
Zip Code:
F-29
JUL 12
Page 2 of 2 Pages.
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