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New Jersey Department of Health Consumer, Environmental and Occupational Health Service Public Health and Food Protection Program PO Box 369, Trenton, NJ 08625-0369 Telephone: (609) 826-4935 https://nj.gov/health/cottagefood APPLICATION FOR COTTAGE FOOD OPERATOR PERMIT SECTION I – APPLICATION INFORMATION Application Date Check or Money Order/Payment Confirmation Number Payment Date Type of Request A new permit. Renewal of an existing permit. License number: SECTION II – APPLICANT INFORMATION Applicant Name First Name Middle Initial Last Name Business trade name or “doing business as” (DBA) name (if applicable) Applicant Residential Street Address (this must be the same as the location of the kitchen at which applicant will prepare cottage food products) Street Address 1 Street Address 2 City State Zip Code Mailing Address (if different than applicant residential address) Street Address 1 Street Address 2 City State Zip Code Telephone Number Email Address (at which applicant will receive official Department communications) • See the following web page for application instructions and submission options: nj.gov/health/cottagefood • Complete all information. The Department will not process incomplete applications. • Application fees are non-refundable. IMPORTANT: This application is subject to public access and disclosure pursuant to N.J.S.A. 47:1A-1 et seq., and other laws. If privacy or confidentiality concerns exist with respect to information the applicant must supply in support of this application, please email the Cottage Food Project at cfo@doh.nj.gov before submitting application. STATE USE ONLYCFO-1Page 1 of 3 SECTION III – COTTAGE FOOD PRODUCT INFORMATION Indicate the information below for the non-TCS food that the applicant will produce as a cottage food operator. Applicant should indicate each major food allergen that a product type is likely to contain, click all that apply. Enter more products on page 3. *Note: Requests for approval of other non-TCS food products not listed may be submitted to the Department in writing pursuant to N.J.A.C. 8:24-11. Product Type Product Name Application for Cottage Food Operator Permit Product Type Product Name Product Type Product Name Product Type Product Name Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree

oduct Type Product Name Product Type Product Name Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Sesame Sesame Sesame SesameCFO-1 FEB 25

-If Yes, submit a copy of microbiological (total coliform) analysis of the private well water that is conducted using samples collected no earlier than 60 days prior to the filing date of this application. -If No, submit a copy of most recent water bill for the location of the cottage food kitchen. I am a certified food protection manager in good standing with the accredited program. I attach a true copy of my food protection manager certificate or other proof of my credential. I am aware that my gross annual sales from cottage food products cannot exceed $50,000. If this is an application to renew my existing cottage food operator permit, I represent that in the past year, gross sales receipts from cottage food products did not exceed $50,000. Photocopies of original records that I am submitting with this application are true, complete, and correct copies of the original records. I certify that the statements I make in this application are true. I am aware that if any statement I make in in this application is willfully false, I am subject to civil administrative penalties under N.J.A.C. 8:24-8.9, denial of my application and/or revocation of my permit. By typing my name below, I intend to sign this Application for Cottage Food Operator Permit. Name of Applicant: ______________________________________________ Date: ____________________ SECTION IV – APPLICANT REPRESENTATIONS AND CERTIFICATION Application for Cottage Food Operator Permit (continued) Page 2 of 3 Facility Requirements The cottage food operation is in a private dwelling where I reside. All cottage food products are prepared in the private kitchen within my home. Sleeping quarters are excluded from areas used for cottage food preparation and storage. Sanitation Requirements Handwashing facilities are conveniently located, accessible, and supplied with warm running water, soap, and clean paper towels Kitchen equipment and utensils used for cottage food preparation are clean and in good repair. Food contact surfaces are cleaned and sanitized before each use. The premises are maintained free of rodents and insects. Cottage Food Preparation and Packaging Requirements Food workers wash their hands before working with food, and after any activity that contaminates the hands such as after using the restroom, eating, smoking, or touching pets. Food workers do not handle ready-to-eat food with their bare

working with food, and after any activity that contaminates the hands such as after using the restroom, eating, smoking, or touching pets. Food workers do not handle ready-to-eat food with their bare hands. Single-use gloves, tongs, or other effective means are used. If used, single-use gloves are changed or replaced as often as handwashing is necessary. Limitations/Exclusions During Cottage Food Preparation and Packaging Domestic activities such as family meal preparation, dishwashing, clothes washing, and kitchen cleaning are not conducted. Infants, children and pets are excluded from the kitchen. Potable drinking water is used for handwashing and warewashing, and as a cottage food product ingredient. Smoking is prohibited. Ill food workers are excluded from the kitchen. Prerequisite Information I have checked with my local municipal government and there are no local ordinances or zoning requirements that would prevent me from operating a home-based food business. Does the cottage food kitchen use private well water?CFO-1CFO-1 FEB 25

CFO-1Page 3 of 3Application for Cottage Food Operator Permit (continued) Product Type Product Name Product Type Product Name New Jersey Department of Health Consumer, Environmental and Occupational Health Service APPLICATION FOR COTTAGE FOOD OPERATOR PERMIT Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Product Type Product Name Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Major Food Allergens Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Shellfish Soybean Shellfish Soybean Shellfish Soybean Soybean Soybean Eggs Soybean Milk Tree Nuts Eggs Peanuts Milk Tree Nuts Eggs Peanuts Milk Tree Nuts Eggs Peanuts Fish Wheat Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Peanuts Fish Wheat Shellfish Shellfish Soybean Shellfish Soybean Shellfish Soybean Soybean Soybean Eggs Soybean Fish Wheat Fish Wheat Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Peanuts Fish Wheat Shellfish Eggs Soybean Milk Tree

sh Wheat Fish Wheat Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Peanuts Fish Wheat Shellfish Eggs Soybean Milk Tree Nuts Eggs Peanuts Fish Wheat Shellfish Soybean Milk Tree Nuts Peanuts Fish Wheat Shellfish Eggs Soybean Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame Sesame SesameCFO-1 FEB 25