Form M-6 - Renewal Application To Operate A Frozen Dessert Plant printable pdf download

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

Less than $100,000.00........................................................................................ $150.00

In excess of $100,000.00, but not in excess of $500,000.00.............................. $300.00

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

Form M-6 - Renewal Application To Operate A Frozen Dessert Plant

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