New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 369

Trenton, NJ 08625-0369

INITIAL APPLICATION FOR LICENSE

TO MANUFACTURE FROZEN DESSERTS	state use only
In-State frozen desserts manufacturers should indicate gross	Fee

wholesale business during last fiscal year (check applicable box)	Schedule

Less than $100,000.00	$100.00

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

Excess of $500,000.00	$500.00

Out-of-State wholesale frozen dessert manufacturers	$100.00

Mobile units	$50.00

MAKE CHECK OR MONEY ORDER PAYABLE TO:

“NEW JERSEY DEPARTMENT

OF HEALTH”

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

Check/Money Order No.

Date of Check/Money Order

Amount

Date of Application

IDENTIFICATION
Name of Owner(s) or Corp.

If Mobile Unit (Year and Make of Truck)

Trade Name

Vehicle Identification No. (VIN)

Telephone Number

County

Depot Location

If Incorporated, Name of State

Federal ID / Social Security No.

City

State

Zip Code

Establishment Location

Mailing Address (If Different Than Location)

City

State

Zip Code

City

State

Zip Code

BRANDS UNDER WHICH FROZEN DESSERTS ARE SOLD
Brand Names:

MILK PRODUCTS MIX PURCHASED OR RECEIVED FROM
Name

Name

Street Address

Street Address

City	State	Zip

City	State	Zip

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

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

INITIAL APPLICATION FOR LICENSE TO MANUFACTURE FROZEN DESSERTS

(Continued)

M-5

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

M-5 Initial Application for License to Manufacture Frozen Desserts

M-5, food and drug safety, milk program,

EWhite

2003-10-28

NJDOH