Form M-6 "Renewal Application to Operate a Frozen Dessert Plant" - New Jersey

What Is Form M-6?

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 January 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 M-6 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 M-6 "Renewal Application to Operate a Frozen Dessert Plant" - 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
Check/MO Date:
Trenton, NJ 08625-0369
Phone: 609-826-4935
Amount:
RENEWAL APPLICATION TO OPERATE A FROZEN DESSERT PLANT
Logger Initials:
PURSUANT TO N.J.S.A. 24:10-73.10
June 30,
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.”
FROZEN DESSERT PLANT
1. Trade and/or brand names of all manufactured products:
2. Sources of milk, cream, or mix:
3. In-state wholesale Frozen Dessert Manufacturer:
ANNUAL FEE
a.
Less than $100,000.00........................................................................................ $150.00
b.
In excess of $100,000.00, but not in excess of $500,000.00.............................. $300.00
c.
In excess of $500,000.00 .................................................................................... $500.00
4. Out-of-state wholesale Frozen Dessert Manufacturer............................................................ $100.00
5. Mobile Unit ................................................................................................................................ $50.00
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
M-6
JAN 13
New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check/Money Order No.:
PO Box 369
Check/MO Date:
Trenton, NJ 08625-0369
Phone: 609-826-4935
Amount:
RENEWAL APPLICATION TO OPERATE A FROZEN DESSERT PLANT
Logger Initials:
PURSUANT TO N.J.S.A. 24:10-73.10
June 30,
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.”
FROZEN DESSERT PLANT
1. Trade and/or brand names of all manufactured products:
2. Sources of milk, cream, or mix:
3. In-state wholesale Frozen Dessert Manufacturer:
ANNUAL FEE
a.
Less than $100,000.00........................................................................................ $150.00
b.
In excess of $100,000.00, but not in excess of $500,000.00.............................. $300.00
c.
In excess of $500,000.00 .................................................................................... $500.00
4. Out-of-state wholesale Frozen Dessert Manufacturer............................................................ $100.00
5. Mobile Unit ................................................................................................................................ $50.00
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
M-6
JAN 13