New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 369

Trenton, NJ 08625-0369

INITIAL APPLICATION FOR

A MILK PLANT OR A BULK MILK HAULER PERMIT

(N.J.R.S. 24:10-57.2)	FOR STATE USE ONLY
FEE SCHEDULE: 0-25 Farms = $50.00 Over 25 Farms = $100.00

Complete all pages. Mail original copy, with your fee, to the above address. Retain a copy for your records.

Make Check or Money Order payable to the “New Jersey Department of Health.”
Check/Money Order No.

Date of Check/Money Order

Amount

Date of Application

IDENTIFICATION
Application for:

Milk Plant

Bulk Milk Hauler	Purpose of Permit:

Milk, cream for manufacturing purposes only

Processing of fluid milk and fluid milk products	Total Number of Dairy Farms supplying milk directly to this plant:
Name of Owner(s) or Corp.

Establishment Location

Trade Name

City

State

Zip Code

Telephone Number

Telephone Number (if different)

County Registered

If Incorporated, give Name of State

Federal ID / Social Security Number

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

Registered NJ Agent (Full Name)	Address	City	State	Zip Code

Name of Applicant

Date of Application

PERSONS OR COMPANIES DESIRING TO PURCHASE

MILK, CREAM, OR MILK PRODUCTS FROM THIS PLANT
Name

Name

Name

Street Address

Street Address

Street Address

City	State	Zip

City	State	Zip

City	State	Zip

Quantity

Quantity

Quantity

Does this supply have separate so called Grade “A” and Grade “B” operations?

Yes No	If Yes, for which plant or supply is your application made?

Grade A Grade B
Number of:	Type of Products Manufactured:
Producers handling milk cans
Producers handling milk in Farm Bulk Tanks
Field inspectors employed by your plant
Is “farm separated cream” received at this plant?	Yes No

Do any other plants supply milk or fluid milk products to this plant?	Yes No
Name of Supplying Plant

Name of Supplying Plant

Street Address

Street Address

City	State	Zip

City	State	Zip

Products Received From Them

Products Received From Them

Name of Applicant

Date of Application

Does the plant operate a quality control program?	Yes No
Are all farms inspected by operator?	Yes No
Times per year:
Is inspection form used? (Pplease attach a sample copy.)	Yes No
Are full records of inspection and reinspection maintained at plant?	Yes No
Which Abnormal Milk Screening Test is run on producer milk?
Are all cattle tuberculin tested?	Yes No
How often?
Are all herds tested for Brucellosis yearly?	Yes No
Are all herds Ring tested for Brucellosis semi-annually?	Yes No
Are full records of herd examination maintained at the plant?	Yes No
Are tests performed by operator on each producers’ milk?	Yes No
Are laboratory tests performed on all producers’ milk?	Yes No
Are laboratory tests made of finished products?	Yes No
Is all milk and/or cream handled in plant produced under regulations of an official milk control agency?
List each agency:

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

APPLICATION FOR A MILK PLANT OR A BULK MILK HAULER PERMIT

(Continued)

M-3

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

M-3 Initial Application for a Milk Plant or a Bulk Milk Hauler Permit

EWhite

2003-10-10

NJDHSS