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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