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 Hotel/Motel Permit

To: Hotel and Motel Owners/Operators
From: The Northeast District Department of Health Date: November 8, 2022
Subject: 2023 Permit Renewal

Fee: $125.00

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 Thursday, December 15, 2022:

•	A completed Hotel/Motel 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 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, 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

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

MOTEL / HOTEL REGISTRATION

Establishment Name: 				 Location: 	Email: 		 Mailing Address: 		
City: 			State: 	Zip:		 Phone: 		Fax: 				 Manager: 	Emergency Contact: 		

Owner: 		Home Phone: 		 Address: 				 City: 	State: 	Zip: 	

Number of Rooms: 	Any Long-Term Rental Units? Yes 	No 	
Sewage Disposal:
Septic System	Public Sewer	
If septic system, what was the last date is was pumped? 	/	/	

Water Supply:
Private well	 If Private well, is it:

Public Water: 	

Drilled 	or Dug 	
Date Water Last Tested: 	/	/	

Is There Any Food Service Conducted At Your Establishment? Yes 	No 	

Signature: 	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