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 

SERVICE APPLICATION

COSMETOLOGY: 		 BARBER: 		 NAIL SALON: 	 OTHER: 		

Name of Establishment: 	

Business Street Address: 			 Town: 				

Legal Owner of Business: 	

Billing Email: _________________________________________________________________

Mailing Address for Business: 	

Town: 		 State:	 	 Zip: 		 Business Tel:				

Manager Name: 	

Mailing Address: 	

Town: _______________ State: _____ Zip: ________ Tel:	 ___________	Fax: _____________

Number of Workstations/Chairs: 	 Business Hours: 					

Sewage Disposal: Public: 	 Private: 		 Date Last Pumped: 			

Water Supply:  Public: 	 Private: 	 Date Last Tested: 					

  ****************************************************************************
List all operators below including name, license type, and license number with expiration date.  (Attach additional sheets if necessary)

NDDH Use Only		File/ID # __________________________ Fee: _______________ 
Date: ___________   Check # ___________________     CC    E-Check     Cash     Receipt #_________________   
Date: ___________   Late/Penalty/Other Fee: ___________ Check # _______________   CC     E-Check     Cash    
Receipt #______________

NDDH Use Only	
Date: ___________ Fee: _______ Check # _________     CC    E-Check     Cash     Receipt #_________________   
Date: ___________ Fee: _______ Check # _________     CC    E-Check     Cash     Receipt #_________________

Signature of Owner/Operator:							 Date: 			
NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card

NDDH Use Only		File/ID # __________________________ Fee: _______________ 
Date: ___________   Check # ___________________     CC    E-Check     Cash     Receipt #_________________   
Date: ___________   Late/Penalty/Other Fee: ___________ Check # _______________   CC     E-Check     Cash    
Receipt #______________

NDDH Use Only		File/ID # __________________________ Fee: _______________ 
Date: ___________   Check # ___________________     CC    E-Check     Cash     Receipt #_________________   
Date: ___________   Late/Penalty/Other Fee: ___________ Check # _______________   CC     E-Check     Cash    
Receipt #______________

NDDH Use Only
File/ID #:			_____________ Fee: _______________ Date: ______________
Check #   	___      ________     Receipt # 	      _________          Cash                 Credit Card