Form Center

2. Borough of Hawthorne

   Board of Health

   445 Lafayette Avenue, 2nd Floor
   Hawthorne, NJ 07506

   Phyllis Wooldridge

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

   https://hawthornenj.org/269/Health

4. Form must be filled in completely before a license can be issued. PLEASE PRINT!
6. Business Name*
8. Business Address*
10. Business Phone Number
11. License Plate Number
13. Business Owner Name*
15. Home Address
17. Home Telephone Number
21. • List below the names of dealers who make deliveries to your store
    • Mobile trucks must list names of industries served
23. Dealer Name, Address, and Product

    Please number each item. 

25. Annual Fee: $250 - 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. 

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

    
    

27. Licenses are not transferable and must be renewed each year before January 31.
29. Signature of Applicant*
30. Date*
Leave This Blank:


31. Print Only

* indicates a required field