I hereby make application for a license to conduct a retail food establishment in the Township

of Upper Freehold. The fee is $100.00 for all establishments where food is handled; $50.00

for a mobile unit selling retail.

Name of Establishment:___________________________________________________

Establishment Address:___________________________________________________

                                   ___________________________________________________

Phone Number:_________________________________________________________

In making this application, I agree to comply with all of the Ordinances of the Township of

Upper Freehold and the Laws of the State of New Jersey covering such establishments. It

is further agreed that I will surrender this license, if same is granted, to the Upper Freehold

Township Board of Health on demand.

Printed Name of Owner: __________________________________________________

Owner’s Address: _______________________________________________________

_____________________________________________________________________

Phone Number:_________________________________________________________

Signature of Owner: __________________________________ Date:_______________

(For Board of Health Use Only)

License # Issued: __________________ Date Issued: _____________