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

ITINERANT FOOD VENDING APPLICATION

Vending Name: 											

Owner Name: 					 Contact: 						

Mailing Address: 				 City: 			 State: 		 Zip: 		

Business Phone: 			 Home Phone: 				 Cell: 			

Fax: 					 Billing Email: 						

Type of operation: 	On-site preparation: 		 Off-site preparation:		

Vehicle Registration Number(s): 									

        Schedule of Proposed Sites  /    Hours of Operation  /       Location of Toilet Facilities

______________________     __________________     __________________________

______________________     __________________     __________________________

______________________     __________________     __________________________

______________________     __________________     __________________________

Menu: _______________________________________________________________________

_____________________________________________________________________________

Water supply: City _____ Well _____ Date last tested (if well):_____________
(A water analysis must be submitted in order to receive your permit.  If more than one well is to be used, analysis reports must be submitted for each.)

Method of wastewater disposal: ____________________________________________________

Method of disposal of fryer grease or other ingredients: _________________________________

You must submit written notification from the appropriate municipal authorities indicating that the proposed operation conforms to all local/town requirements.

Signature: __________________________________________ Date: _____________________

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