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2. Borough of Hawthorne
   Health Department 

   445 Lafayette Avenue, 2nd Floor
   Hawthorne, NJ 07506
   Phyllis Wooldridge

   Phone: 973-427-4012  ~  Fax: 973-427-1882

   https://hawthornenj.org/269/Health

4. Name of Applicant*
6. Address*
8. Contact Number*
9. Email Address*
11. Number of Machines*

    The cost of each machine is $40.

13. Location of Machines / Product Dispenses

    Please number each item. 

    The cost of each machine is $40.

15. Annual Fee: $125 - January 1 to December 31 

    Cash or Check only - Checks made payable to: The Borough of Hawthorne

    Please mail or deliver application and fees to the Health Department NO LATER THAN January 31st.  
    Your license will be mailed to you, Please post in public view.
    Thank you for your continued business in  the Borough of Hawthorne. 

    Any questions or concerns may be directed to the Registrar at: pwooldridge@hawthornenj.org

    
    

17. Signature of Applicant*
18. Date*
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19. Print Only

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