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03/12 Fields in Bold are required Page 1 of 2 KRISTINE GABOR Freeholder KEVIN L. THOMAS Public Health Coordinator JOSEPH R.TORDELLA, D.O. Medical Director CAPE MAY COUNTY DEPARTMENT of HEALTH 4 Moore Road Cape May Court House, N.J. 08210-1601 (609)465-1209 after hours (609) 465-1190 Fax: (609) 465-6564 Annual Retail Food Facility Permit Application (For new establishments, application must be submitted at least 30 days before the planned opening date) Owner/Applicant Information Establishment/Facility Information Owner/Applicant Name: Establishment Name: (Street/Mailing Address) (Facility Street address) (City, State, Zip) (Facility City, State, Zip) Ownership Type (Select One) □ Corporation □ Association □ Partnership □ Individual Municipality: Are there other establishments in the County under the same ownership? □ Yes □ No For Profit? (Select One) □ For Profit □ Not for Profit If yes, please list the establishment(s). Contact Information Emergency Contact Name: Emergency Phone: ( ) Contact Title: E‐Mail Address: Manager Name: Primary Phone: ( ) Facility Fax ( ) Establishment Details Days of Operation: # of Food Service Employees: Hours of Operations: Seating Capacity (Select One) □ 25 or less □ 26‐100 □ More than 100 Annual Status (Select One) □ Open all year □ Seasonal* *Operating in only June, July, August Water‐Sewage Information (Select One) □ Public Water/Public Sewage □ Public Water/Private Sewage □ Private Water/Public sewage □ Private water/Private Sewage ---PAGE BREAK--- 03/12 Fields in Bold are required Page 2 of 2 CAPE MAY COUNTY DEPARTMENT of HEALTH Annual Retail Food Facility Permit Application (For new establishments, application must be submitted at least 30 days before the planned opening date) (Continued) Facility type: (select one) 01 Agricultural Market / Produce 12 Grocery Store 02 Bar & Liquor Store 13 Bar / Restaurant 03 School Cafeteria 14 State/County Facility 04 Hospital 15 Meat, Poultry Market 05 Catering Kitchen 16 Mobile Food Establishment (Other 06 Church/Non-Profit/Private Org 17 Mobile Food Establishment (Frozen) 07 Tavern Or Night Club 20 Youth Camp 08 Fish Market 21 Retail Bakery 09 Specialty Store 22 Restaurant 10 Delicatessen 23 Supermarket 11 Day Care Center 26 Luncheonette / Snack Bar / Piz I, the undersigned, attest to the accuracy of the information provided in this application. Applicant Print Name: Signature of Applicant: Date: YOU MUST ATTACH A COPY OF YOUR MENU TO THIS APPLICATION Retail food establishments must meet the requirements set forth in N.J.A.C. 8:24‐“Sanitation in Retail Food Establishments and Food and Beverage Vending Machines.” N.J.A.C. 8:24 provides definitions; sets standards for management and personnel, food operations, and equipment and facilities; and provides for retail food establishment plan review, inspection, and employee restrictions. Upon County Health Department review and acceptance of payment, this permit application for operating a food establishment in Cape May County is valid for the calendar year.