2. OFFICE OF THE TOWNSHIP CLERK

   95 West Veterans Highway

   Jackson, NJ 08527

   (732) 928-1200 | Fax (732)928-4377

4. APPLICATION FOR ANNUAL MOBILE FOOD REGISTRATION

   Vendors who have more than one truck must apply for a license for each truck
   

8. *MOBILE FOOD LICENSE REGISTRATIONS ARE VALID UNTIL DECEMBER 31st* 
   

10. Application is hereby made to the Board of Health and to Jackson Township for a license to operate a Business.
12. Name of Establishment
14. Address of Establishment
16. If granted, this license is to be issued in the name of
18. Corporation Name:
20. Address of Applicant:
22. City
23. State
24. Zip Code
26. Business Number
27. Cell Number
28. Email Address
30. Does this establishment provice catering or delivery?

    1. Catering

    1. Delivery
31. Are foods prepared at another location?

    1. YES

    1. NO
33. If YES, please provide name and address of the location below.
35. If establishment is owned by an out of state owner or corporation, please provide name and address of regional office, name of contact person, telephone number and email address:
37. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Signature of Applicant

41. Do Not Complete Below

    ***************************************************************************************

    HEALTH OFFICER’S INSPECTION REPORT
    Inspection of the above premises was completed on _____________________ and it is recommended that
    The licensed BE______ NOT BE_____ issued. If recommendation is for non-issuance, attach inspection report. 

                                                                                                       ___________________________________
                                                                                                                                     HEALTH OFFICER 
    
    

43. APPLICATION FOR ANNUAL MOBILE FOOD REGISTRATION

    VENDOR’S REGISTRATIONINFORMATION

45. Please provide and include the following with this application:(SEE PAGE 3-4) 

    Certificate of Liability Insurance–Acord form with Jackson Township as additional insured:

    Minimum coverage–Personal Injury $100,000/$300,000 

    Property Damage $50,000

    Copy of Vehicle Registration card and Driver’s license (of all employees) 

    Copy of Ocean County Health Department “Satisfactory” certificate 

    Two (2) 1-inch square photos of each person selling food.

47. Business Name
49. Business Address
51. City
52. State
53. Zip Code
55. Phone Number
56. Email Address
58. Vehicle Information:
60. Year, Make & Model
61. Upload Photo
63. License Plate Number
64. VIN Number
66. Applicant Name:
68. SEX:
69. RACE:
70. HEIGHT:
71. WEIGHT:
73. SCARS:
74. TATTOOS:
76. Applicant Address:
78. Applicant’s place of residence (last 5 years):
80. Complete description of business:
82. Has the applicant ever had an application to conduct a vending business denied or revoked?

    1. Yes

    1. No
84. If YES, please provide the details below:
86. Has the applicant ever been convicted of a crime?

    1. Yes

    1. No
88. If yes, please provide details.

90. Certificate of Liability Insurance – Acord form with Jackson Township as additional insured:

    Minimum coverage–Personal Injury $100,000/$300,000

    Property Damage $50,000

92. Upload Certificate of Liability Insurance
94. Copy of Vehicle Registration card and Driver’s license (of all employees)
96. Copy of Ocean County Health Department “Satisfactory” certificate
98. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
100. Electronic Signature
101. Date
     Date
103. Township Clerk’s Office

105. DO NOT WRITE BELOW-MUNICIPAL USE ONLY

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     CODE ENFORCEMENT APPROVAL _______________________ DATE: _____________________

     FIRE DISTRICT APPROVAL ____________________________ DATE: _____________________

     (Excludes: ice cream trucks) 

     OCEAN COUNTY BOARD OF HEALTH APPROVAL ______________________________________

Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit Submit and Print

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