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 Food Service Permit
To: Food Service Establishment Owners
From: The Northeast District Department of Health Date: November 8, 2022
Subject: 2023 Food Service Permit Renewal

The Food Service permit 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.

Please return the following to this office by Thursday, December 15, 2022:
•	A completed Food Service 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 7/1/22, can be found online at:
https://www.nddh.org/wp-content/uploads/2022/07/NDDH_Service_Fees_effective_070122.pdf
•	Establishments that are a Class II, III or IV must provide a copy of the Certified Food Protection Manager Certificate
•	Complete and return the Emergency Contact Form
•	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.
•	Establishments with grease traps must provide a copy (receipt) of the most recent maintenance

Upon receipt of all necessary documentation, a permit will be issued for your establishment which will be valid from January 1st through December 31, 2023. 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 Thursday, December 15, 2022, 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 1 through January 13, 2023, inclusive.

Annual inspections will be conducted throughout the year. A re-inspection fee of $120 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

Definitions

"Catering food service establishment" means a business that is involved in the (A) sale or distribution of food and drink prepared in bulk in one geographic location for retail service in individual portions in another location, or (B) preparation and service of food in a public or private venue that is not under the ownership or control of the operator of such business;

"Class 1 food establishment" means a food establishment that only offers for retail sale (A) prepackaged food that is not time or temperature controlled for safety, (B) commercially processed food that (i) is time or temperature controlled for safety and heated for hot holding, but (ii) is not permitted to be cooled, or (C) food prepared in the establishment that is not time or temperature controlled for safety;

"Class 2 food establishment" means a retail food establishment that does not serve a population that is highly susceptible to food-borne illnesses and offers a limited menu of food that is prepared, cooked and served immediately, or that prepares and cooks food that is time or temperature controlled for safety and may require hot or cold holding, but that does not involve cooling;

"Class 3 food establishment" means a retail food establishment that (A) does not serve a population that is highly susceptible to food-borne illnesses, and (B) has an extensive menu of foods, many of which are time or temperature controlled for safety and require complex preparation, including, but not limited to, handling of raw ingredients, cooking, cooling and reheating for hot holding;

"Class 4 food establishment" means a retail food establishment that serves a population that is highly susceptible to food-borne illnesses, including, but not limited to, preschool students, hospital patients and nursing home patients or residents, or that conducts specialized food processes, including, but not limited to, smoking, curing or reduced oxygen packaging for the purposes of extending the shelf life of the food;

"Food establishment" means an operation that (A) stores, prepares, packages, serves, vends directly to the consumer or otherwise provides food for human consumption, including, but not limited to, a restaurant, catering food service establishment, food service establishment, temporary food service establishment, itinerant food vending establishment, market, conveyance used to transport people, institution or food bank, or (B) relinquishes possession of food to a consumer directly, or indirectly through a delivery service, including, but not limited to, home delivery of grocery orders or restaurant takeout orders or a delivery service that is provided by common carriers. "Food establishment" does not include a vending machine, as defined in section 21a-34 of the general statutes, a private residential dwelling in which food is prepared under section 21a-62a of the general statutes or a food manufacturing establishment, as defined in section 21a-151 of the general statutes;

“Itinerant food vending establishment” means a vehicle-mounted, self-contained, mobile food establishment; All Itinerant food vending establishments are required to have a hand-washing sink with hot and cold running water under pressure, holding tank, and mechanical refrigeration.

“Pushcarts” are limited to the sale of hot dogs and pre-packaged foods only.

“Multiple class food service establishment” means any business with departments that are classified as separate food establishments;

“Noncommercial function” means a function where food is sold or distributed by a person not regularly engaged in the business of selling such food for profit;

“Permit” means a written document issued by a director of health that authorizes a person to operate a food establishment;

“Seasonal operation” means a food establishment that operates six months or less at the same geographic location;

"Temporary food service establishment" means a food establishment that operates for a period of not more than fourteen consecutive days in conjunction with a single event or celebration.

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

FOOD SERVICE PERMIT APPLICATION

Establishment Name: 	

Physical Address: 	

City: 	State: 	Zip: 	

Mailing Address: 	

City: 	State: 	Zip: 	

Phone: 	Fax: 	Billing Email: 	

Owner of Establishment: 	

Home Address: 	City: 	State: 	Zip: 	

Home/Cell Phone: 	Email: 	

Manager/Operator: 	

Home Address: 	City: 	State: 	Zip: 	

Home/Cell Phone: 	 Operating Hours: 	Seating Capacity: 	

Establishment Type:
Restaurant/Food Service*		Caterer*	
*If caterer, do you have onsite catering? Yes	No	Do you have offsite catering? Yes	No	

Seasonal	Date Open: 	
Date Closed: 	

Food Store	 Campground		

Bakery	 Day Care		

Non-profit	(Tax Exempt Required #	) School		Youth Camp	

Sewage Disposal:	Water Supply:

Septic System	 Public Sewer	 
Last Date Pumped	/	/	

Public Water	
Private Well	 Water Treatment: Yes	No (wells only)
Last Date Tested	/	/	

Please Complete Reverse Side of Application

Rev 100521

Page 1 of 2

Grease Disposal Units-Past Year Cleaning and Maintenance: (Required-Class III and IV)
Date of Cleaning	Name/Authorized Cleaner	Address of Cleaner	Phone for Cleaner	

				

Certified Food Protection Manager: (Required-Class III and IV)
Head CFPM Name: 	
Type of Certified Food Protection Manager Certification: (Check 1, 2, 3 or all which apply and provide a copy.)
1.	National Restaurant Association (ServSafe): 	
2.	Prometric: 	
(Formerly Thomson Prometric, Experior Assessments, National Assessment Institute, Chauncey, and Education Testing Service)
3.	National Registry of Food Safety Professionals/Environmental Health Testing: 	
4.	360training.com 	
Does your establishment have CFPM alternates?* Yes	No	If so, how many? 	
Alternate CFPM Name: 	
*A CFPM alternate can be a CFPM, a FAST-certified employee, or someone trained by the head CFPM in safe food handling w/training records.
Does your establishment maintain training records?* Yes	No	
*Training records can be a notebook or binder which contains copies of employees’ CFPM and FAST certificates along with dates of in-house and outside food safety trainings.

Other Permits:
Dept. of Consumer Protection	 Dept. of Agriculture		 CT Liquor Commission 		

Permit #	 Permit #	 Permit #	

Expiration Date	 Expiration Date	 Expiration Date	

IMPORTANT: If any information changes throughout the permit year, contact the Northeast District Department of Health to update our records.

Signature: 	Date	

Print First and Last Name: 	

NDDH Use Only:	Class: 1		2	3	4		CC		E-Check	 Cash Food Service Permit Fee: 		 Receipt #		 CK#		 Date	 /	 /	  Late/Penalty/Other Fee: 		Receipt #		CK#		Date	/	/	

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 http://www.nddh.org/services/food/.
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