Application For Annual Homestead License printable pdf download

STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

MAIL TO: BUREAU OF FINANCE/RECEIPTS UNIT-FOOD PROTECTION

129 PLEASANT STREET, CONCORD, NH 03301

Telephone: 603-271-4589

FAX: 603-271-4859

TDD Access: 1-800-735-2964

Website:

E-mail: foodprotection@dhhs.state.nh.us

APPLICATION FOR ANNUAL HOMESTEAD LICENSE

NOTE: See Reverse for Instructions.

RS-405263

Full Legal Name of Corporation, LLC or Owner(s)

Name of Establishment

Location (Street)

(Town, State)

(Zip)

Mailing Address (if different)

(Town, State)

(Zip)

Telephone # of Establishment (

)

Emergency Contact Telephone # (

)

Email Address

Name of Person in Charge at Establishment

Type of License

Type of Ownership

Current Establishment #

Sole Proprietorship

Corporation

New Establishment

Current License #

Joint Venture

Limited Liability

Change in License Class

Town Water

Yes or No

Partnership

Other (Specify)

Renewal

Town Wastewater Yes or No

Public Water System/(EPA) #

Homestead-Class H ($150)

Offer food via Internet, to other food establishments/distributors excluding retail food stores,

or gross sales greater than $20,000 annually.

*If offering food from own residence, owner’s farmstand, at a farmers’market, or to a retail food store and

gross sales are under $20,000-no license is required.

*Submit all supporting documentation. Incomplete applications will be returned.

Written results of laboratory analysis of water for bacteria, nitrates and nitrites. (n/a if Town Water)

On a separate piece of paper, please submit a complete list of the product(s) you are manufacturing. Be specific, for example if

you are making cookies, list each kind you make. Add new products by submitting an amended list at that time.

Check if applicable. “My jams and jellies are made using the standardized recipes on http:// nchfp.uga.edu/ or

Check if applicable. “I do not make my jams and jellies using the standardized recipes from the above websites”, therefore I

have included a copy of the process review for each recipe as required in He-P 2311.05.

, “jarred” foods,

For other

as, but not limited to: BBQ and hot sauces, mustards, pepper jellies, etc., include a

processed

such

copy of the process review. See reverse for information for process review.

Copy of a sample of finished product labels. Labels must include all of the following information.



The common or usual name of the product.



The name and address of the manufacturer’s, packer’s, or distributor’s business.



The ingredients in descending order of predominance by weight.



The net weight, volume, or numerical count in both U.S. customary and metric;



A product code which includes date of manufacture, container size, and product lot or batch number to aid in a recall

of product in case of a public health hazard. Note:this number can be your “baked on” date.



List of major allergens.



Homesteads shall label each product with the following statement: “This product is made in a residential kitchen

licensed by NHDHHS.”

Note: Foods that require refrigeration, potentially hazardous foods and acidified foods such as pickles, relishes, salsa

are prohibited from being made in the residential kitchen.

17,18

I, (print name & title)

______________________________________________________, certify that all information provided in or attached to

this application is complete, accurate and up-to-date as of the date specified below. I further certify that there are no willful misrepresentations of

the answers to questions herein, and that I have made no omissions with respect to any of my answers to the questions presented. I understand that

it is my responsibility to immediately notify the Food Protection Section with regard to any changes, corrections or updates to the information

provided.

SIGNATURE OF APPLICANT:

___________________________________________________DATE OF APPLICATION:

_________________

-----------------------------------------------DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY-----------------------------------------------

Date Received___________Check #_______________________Check Amount___________ Audit #___________

_______________

______________

Provisional Date

Final Date

Ldb_____ Scn_____E/H

NH Department of Health & Human Services, Food Protection Section

Form# HAPP 11-01-15

R:\OCPH\EPI\FPS\Group\Applications (lic, fp, var\Food Applications PDF\ 2015 Homestead App 11-01-15.doc pg 1

Application For Annual Homestead License

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