Northeast District Department of Health

69 South Main Street, Unit 4, Brooklyn, CT 06234
Phone: (860) 774-7350 / Fax (860) 774-1308 / www.nddh.org

An Important Notice Regarding Your Bed and Breakfast Registration

To: Bed and Breakfast Owners
From: The Northeast District Department of Health Date: November 15, 2021
Subject: 2022 Registration

Fee: $50.00

The registration issued to your establishment by the Northeast District Department of Health (NDDH) will expire on December 31st and must be updated on a yearly basis. We are eager to assist you in complying with the State of Connecticut public health regulations.

Please return the following to this office by close of business Wednesday, December 15, 2021:

A completed Bed and Breakfast Application. You may access the application forms and can make payment online at www.nddh.org/formspermits. If you do not have computer access, you may pick up the forms and pay the application fee at our office at 69 South Main Street, Brooklyn, during regular business hours (Monday-Thursday, 8am – 4pm, Fridays, 8am – noon).
The appropriate fee paid online at https://www.nddh.org/pay-online/, brought to our office, or mailed with your application to 69 South Main Street, Unit 4, Brooklyn, CT 06234. The fee schedule, effective 7/1/21, can be found online at https://www.nddh.org/wp- content/uploads/2020/06/NDDH_Service_Fees_070120_BoH_Approved-05.28.20-1.pdf.
Establishments with public water must provide a copy of the most recent water bill.
Establishments with a private well must provide a copy of the current water analysis report. Note that the water sample must have been retrieved by a CT Certified laboratory.
Establishments with an on-site septic system must provide a copy (receipt) of the most recent waste removal. Note that the waste removal must be within the past 3 years.

Upon receipt of all necessary documentation, a permit will be issued for your establishment which will be valid from January 1st through December 31, 2022. Please be sure to provide us with a valid e-mail address, as we will be sending permits electronically. Also be sure to complete and return the Emergency Contact Information Form.

All necessary documentation and permit fees must be received by close of business on Wednesday, December 15, 2021 or the establishment will be charged a late fee of $90. In addition, a penalty fee of $12 per NDDH business day with a maximum of $120 shall be assessed for each business day late from January 3 through January 14, 2022 inclusive.

Annual inspections will be conducted throughout the year. A re-inspection fee of $115 will be charged for a failed inspection.

If you have any questions, please feel free to contact us. As always, we look forward to working with you.
Sincerely,

The Northeast District Department of Health

Sanitarian Approved Initial:	 Date:  	

Emailed: 	

Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone - (860) 774-7350 / Fax - (860) 774-1308
www.nddh.org	email@nddh.org

BED & BREAKFAST APPLICATION

Establishment Information		
Name of Establishment:			
Location:			
Mailing Address:			
City:	State:	Zip:	
Phone:	Fax:		
Manager:		Phone:	
Owner of Establishment:			
Mailing Address:			
City:	State:	Zip:	
Home Phone:	Billing Email:		
Age of House:	# Of Sleeping Rooms Available to Public:

# Of Beds in Each Room:	# Of Bathroom Facilities:
Any long-term rental units?	No	Yes	How many?

Meals Offered (Check All That Apply)

Continental Breakfast	Full Breakfast	None
Brunch	Lunch
Dinner	Other

Type of Water Supply
Public Water	Private Well
If a private well, select one: Dug	Drilled	Artesian	Other:  	
Any filtering system? No	Yes	If so, what type? _ 	 Date last tested:			_ (Enclose copy of test report)
Type of Sewage Disposal
Public Sewer	Private Septic System

Size of Tank:  	
Date Last Pumped:  	

Square Footage of Leach Area: _	_ Frequency of Pumping:	_

Has the septic system ever been repaired?	No

Yes

Date:  	

Who was the property owner when the system was repaired?  	

Name of Individual
Applying for Permit:  	

Date:  	

NDDH Use Only
Date:	Fee:	Check #	CC   E-Check	Cash	Receipt # 	                               Date:	Fee:	Check #	CC   E-Check	Cash	Receipt # 	

Rev. 111121

Northeast District Department of Health

69 South Main Street, Unit 4, Brooklyn, CT 06234
860-774-7350 / Fax 860-774-1308	www.nddh.org

***EMERGENCY CONTACT INFORMATION***
Water Interruption • Power Outage • Fire • Flood • Contamination • Natural and Man-made Disasters
There are a number of emergencies that can interrupt your establishment. To protect the public, the Northeast District Department of Health (NDDH) must be able to quickly contact decision-makers for your business/organization to provide appropriate guidance. Check our website for regular updates that impact your establishment at https://www.nddh.org.
NDDH will conduct periodic tests of our Emergency Notification Systems. You may receive messages by phone, text, fax, or email. Please complete the information below, being sure to fill all fields accurately:
Today’s Date:  	

Business/Org Name:	_ Business Address:   		
City:	_	State:		Zip:	_

Emergency Contact Name and Title:   		                                                                           Cell Phone:	Fax Number:  		                                  Work Phone:	Home Phone:	_ Email Address:  				

Alternate Emergency Contact Name and Title:   		                                                              Cell Phone:	Fax Number:  	                                    Work Phone:	Home Phone:  	  Email Address:  				
Is water for your business establishment/organization supplied by:
 	Well	 	Community Water System

NDDH USE ONLY:

Updated - EHS Database:	Excel Data Sheet:	 	_ Initials:  	

Businesses with multiple locations: Please complete a separate form for each location.

REVISED 11/15/21