New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 369

Trenton, NJ 08625-0369

APPLICATION FOR CERTIFICATION

TO HANDLE OYSTERS, CLAMS OR MUSSELS	state use only
Date Received
Certification No.
Name and Mailing Address of Owner, Owners or Corp.

Location of Establishment

Telephone No.

Fax No.

Telephone No.

Fax No.

Trade Name, if any

County

Federal ID/Social Security No.

NAMES AND ADDRESSES OF OFFICERS
President (Full Name)	Address	City	State	Zip Code

Vice-President (Full Name)	Address	City	State	Zip Code

Secretary (Full Name)	Address	City	State	Zip Code

Treasurer (Full Name)	Address	City	State	Zip Code

New Jersey Registered Agent (If Applicable)	Address	City	State	Zip Code

I plan to handle the following types of shellfish:

OYSTERS	Shellstock	Shucked	Frozen

HARD CLAMS	Shellstock	Shucked	Frozen

SOFT CLAMS	Shellstock	Shucked	Frozen

SURF CLAMS/QUAHOGS	Shellstock	Shucked	Frozen

MUSSELS	Shellstock	Shucked	Frozen
I will obtain my shellfish from the following sources:

Harvest My Own	Buy from Harvesters	Buy from Certified Dealers
I will carry on the following wholesale operations regarding raw shellfish:

Shuck and Pack Shellfish	Freeze Shellfish

Repack Shucked Shellfish Purchased from Certified Dealers	Wet Storage

Reship Shucked Shellfish Purchased from Certified Dealers	Depuration

Reship Shellstock Purchased from Certified Dealers	Aquaculture

Ship Shellstock Purchased from Harvesters	Truck Reshipping Only

Surf Clam or Quahog Landing Dock
I will sell oysters, clams or mussels:

In New Jersey Only (N)	Outside New Jersey (I)
CERTIFICATION

I certify that the foregoing statements are true to the best of my knowledge and belief.
Name and Title of Applicant

Signature	Date

F-48

JUL 12

F-48, Application for Certification to Handle Oysters, Clams or Mussels

application for certification, certificate, oysters, clams, mussels, shellfish, F-48, food and drug safety,

EWhite

2003-10-14

NJDOH