BARNEGAT TOWNSHIP BOARD OF HEALTH

APPLICATION FOR FOOD HANDLERS LICENSE

(License expires December 31, 2012)

THE UNDERSIGNED HEREBY MAKES APPLICATION FOR A LICENSE TO CONDUCT AN EATING OR DRINKING ESTABLISHMENT:

NAME OF BUSINESS: _______________________________

ADDRESS OF BUSINESS ___________________________

OWNER’S/CONTACT NAME: _________________________

OWNER’S ADDRESS: ______________________________

TELEPHONE NO. _________________________________

IN MAKING THIS APPLICATION, I OR WE, AGREE TO COMPLY WITH ALL THE ORDINANCES OF THE COUNTY OF OCEAN AND THE LAWS OF THE STATE OF NEW JERSEY COVERING SUCH ESTABLISHMENTS. IT IS FURTHER AGREED THAT I, OR WE, WILL SURRENDER THIS LICENSE, IF GRANTED, TO THE DEPARTMENT OF HEALTH ON DEMAND.

________________________________________

SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE

(FOR OFFICE USE ONLY)

LICENSE NUMBER ISSUED:        _______________

DATE OF ISSUE:                                _______________