Food Service
Plan Review Application

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

Food Plan Review Checklist
STEPS 1-3 ARE REQUIRED TO SUBMIT THE APPLICATION
(checklists with an * include a required document)
Step 1 – Submit the following to initiate an internal review:
Submit the proposed menu*
Submit the floor plan* drawn to scale illustrating location of equipment
Submit Surface Finish Schedule*
Submit copies of hood/ansul plans*, if applicable
Submit Pre-Operational Questionnaire*
Submit Food Service Plan Review Application and Emergency Contact pages 14-16*
Page 17 (Final Signatures) is ONLY submitted as a final step once all inspections have been completed (from NDDH, Fire Marshall, etc.)
Submit payment for Plan Review Fee (by class) listed on Fee Schedule
Step 2 – Review, sign, and submit the following acknowledgement forms:
Confirm you have a Certified Food Protection Manager (CFPM) required for Class 2, 3, and 4 establishments
Submit a copy of the CFPM certificate*
Submit CFPM Demonstrated Knowledge Statement*
Submit Alternate Person in Charge Demonstrated Knowledge Statement*
Step 3 – Review the following information and submit all applicable items:
If on public sewer, confirm any Fats, Oil, and Grease (FOG) requirements with local W.P.C.A (provide floor plan, menu, wastewater discharging equipment specifications to the local W.P.C.A)
If on private septic, file and submit a B-100a* (form in resource section) with NDDH, and confirm any Fats, Oil, and Grease (FOG) requirements
If on private well:
Submit Public Water System Screening Form* (form in resource section pg 22 and 23)
This form is required by CT DPH when a private well will be used for public consumption.
Fill out all application information up until Section 5: For Local Health Use Only
Submit a copy of water test results*
If on public water:
Submit a copy of the last water bill*
Verify all zoning requirements have been approved by local Planning & Zoning Commission/ Department
Contact the appropriate state agencies for specific requirements such as the Department of Consumer Protection food licenses for Bakery, Cottage Food Operation, and Frozen Dessert Retailer (soft serve ice cream) at (860) 713-6160 or the Liquor Control Division at (860) 713-6210
Step 4 – A plan approval letter will be sent once steps 1-3 are complete. You must then:
Submit payment for FSE Permit Fee (by class) listed on Fee Schedule
Schedule a pre-operational inspection once any construction is complete, at least one week prior to your anticipated opening
Final Step – Once a pre-operational inspection has been completed:
Submit the Final Signatures form on Page 17 of the Food Service Plan Review Application*

Purpose Statement
The Northeast District Department of Health (NDDH) requirements for a food service establishment are based on the 2022 Federal Drug Administration (FDA) Food Code, CT Public Health Code, CT General Statutes 19a-36a through 19a-36o, and the NDDH Food Ordinances.
The intent of the Food Service Plan Review is to reduce the occurrence and potential for food-borne illness outbreaks. An NDDH sanitarian will review the application and work with you if any variances with code requirements are found.
Food service establishments include any place where food or drinks are prepared for sale and service to the public both on and off the premises. Establishments include, but are not limited to cafeterias, catering operations, coffee shops, convenience stores, delis, fast food establishments, food trucks, food stores, markets, restaurants, sandwich stands, supermarkets, and taverns.

Any permits to construct or operate from municipal town officials DO NOT constitute as a permit from NDDH to open and operate a food service establishment.

NDDH requires food service operators to complete the Food Service Plan Review for any proposed establishment including new businesses, ownership changes (see definitions for a simple change of ownership form if needed instead of this application in the resource section), renovations, and operational changes. Your signature on the application constitutes your agreement to comply with the requirements for food service establishments.
A permit is required to open and annual permit renewals are required to continue operations. The number of annual inspections required are based on the establishment class type, which can be found on the following page.

When the plan and facility are approved and applicable fees have been paid, NDDH will issue a food service permit for the establishment that will expire at year’s end.

Changes may occur in the Public Health Code of the State of Connecticut. Approval of this plan does not mean that the establishment specified will be exempt from compliance with future code requirements.
Serving food safely begins with the facility in which the food is prepared and served. This plan review process is a step toward achieving that goal. Our best wishes for a successful venture.

Step 1 Details and Resources
Menu
Your menu must include the disclosure and reminder statements and allergen information.
The Disclosure: identifies the food item which may be raw and/or under-cooked. This can be done with any marking, typically an * or other symbol.
The Reminder: informs the consumer of the risk.
“Consuming raw or under-cooked meats, poultry, seafood, shellfish, or eggs may increase your risk of foodborne illness, especially if you have certain medical conditions.”
Public Act 23-115 states menus must have a statement that customers with food allergies should notify waitstaff prior to ordering food.
Floor Plan
Provide plans drawn to minimum scale of ¼ inch = 1 foot showing an accurate layout of the floor plan. A template is provided.
Show the location of all food equipment. Each piece should be clearly labeled. All equipment must be commercial grade and NSF approved. Submit drawings of self-service hot and cold holding units with sneeze guards.
Show equipment for adequate rapid cooling, including ice baths and refrigeration, and for hot- holding potentially hazardous foods.
Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross-contamination of raw and ready-to-eat foods.
Clearly designate adequate handwashing sinks in the food preparation, food dispensing, ware washing areas and toilet facilities.
Provide room size, aisle space, space between and behind equipment location of all doors, and the placement of the equipment on the floor plan.
Include location of floor drains, floor sinks, overhead waste-water lines, and hot water generating equipment.
Include areas such as storage rooms, garbage rooms, toilets, basements/cellars used for storage or food preparation. Show all features of these rooms and the equipment in these areas. Provide additional pages as needed.
Complete Finish Schedule* forms for each room, including floors, walls, ceilings, and coved juncture surface bases. Use the provided form or other equivalent format.
Include specifications demonstrating:
Entrances, exits, loading/unloading, areas, and docks.
Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste-water lines, hot water generating equipment with capacity and recovery rate, backflow prevention, and wastewater line connections.
Lighting schedule with protectors:
At least 110 lux (10 ft. candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units, dry food storage areas, and in other areas and rooms during periods of cleaning.
At least 220 lux (20 ft. candles)
At a surface where food is provided for consumer self-service such as buffets and salad bars or where fresh produce or packaged foods are sold or offered for consumption.
Inside equipment such as reach-in and under-counter refrigerators.
At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, ware washing, equipment and utensil storage, and in toilet rooms.

At least 540 lux (50 ft. candles) at a surface where a food employee is working with food, utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor.
Food Equipment Schedule* should include the make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). A template is provided.
Source water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with
A color-coded flow chart demonstrating flow patterns for:
Food (receiving, storage, preparation, service)
Food and dishes (portioning, transport, service)
Dishes (clean, soiled, cleaning, storage)
Utensils (storage, use, cleaning)
Trash and garbage (service area, holding, storage)
Ventilation schedule for each room
A mop sink or curbed cleaning facility with facilities for hanging wet mops
Garbage can washing area/facility
Cabinets for storing toxic chemicals
Dressing rooms, locker areas, employee rest areas, and/or coat rack as required
Site plan

Floor Plan for:

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

Use this key or provide another clear key.	Scale: 1 square=	ft.
Hand Sink	HS	Bain-Marie	BM	Slicer	SL	Stovetop/Grill	ST	
Mop Sink	MS	Reach-in Refrig.	RR	Food Processor	FP	Broiler	BR	
Prep Sink	PS	Walk-in Refridg.	WIC	Floor Mixer	FM	Microwave Oven	MW	
3-bay sink	3S	Undercounter Refrig.	UF	Stand Mixer	MX	Steamer	SR	
2-bay sink	2S	Ice Machine	ICE	Countertop	Ctr	Fryer	FR	
Dishwasher	DW	Reach-in Freezer	RF	Table	Tbl	Hood	HD	
Hot-water heater	HW	Walk-in Freezer	WIF	Grease Trap	GT	Grease Removal Unit	GRU	

								

Surface Finish Schedule
Establishment Name: 	 Date:   /  /	
Address		Town 	

Check as many selections as apply:
SPECIFY FINISH AND/OR CONSTRUCTION	
	FLOOR	WALLS	CEILING	

KITCHEN	 Ceramic Tile	 Drywall/Epoxy	 Drywall/Epoxy	
	 Vinyl Tile	 Tile (Type)	 Clad Fiberboard	
	 Vinyl Sheet	 FRP	 FRP	
	 Other (specify) 		 Other (specify) 		 Other (specify) 		

STORAGE AREA	 Ceramic Tile	 Drywall/Epoxy	 Drywall/Epoxy	
	 Vinyl Tile	 Tile (Type)		 Clad Fiberboard 		
	 Vinyl Sheet	 FRP	 FRP	
	 Other (specify) 		 Other (specify) 		 Other (specify) 		

DINING AREA	 Ceramic Tile	 Drywall/Epoxy	 Drywall/Epoxy	
	 Vinyl Tile	 Tile (Type)		 Clad Fiberboard 		
	 Vinyl Sheet	 FRP	 FRP	
	 Other (specify) 		 Other (specify) 		 Other (specify) 		

TOILET FACILITY	 Ceramic Tile	 Drywall/Epoxy	 Drywall/Epoxy	
	 Vinyl Tile	 Tile (Type)		 Clad Fiberboard 		
	 Vinyl Sheet	 FRP	 FRP	
	 Other (specify) 		 Other (specify) 		 Other (specify) 		
Note: “Drywall/Epoxy” means sheetrock with epoxy enamel paint. “Clad Fiberboard” means Plastic-coated or metal-clad fiberboard. “FRP” means Fiberglas reinforced plastic

Pre-Operational Questionnaire (circle your response)
Name of Establishment: 	

Menu
Is a proposed menu attached?	YES	NO
Does the menu include a disclosure statement?	YES	NO
Does the menu include a reminder statement?  YES	NO

Floor Plan
Is an accurate to scale floor plan attached?  YES	NO

Required CFPM (class 2, 3, and 4 only)
Is a copy of the CFPM certificate attached?	YES	NO
Is a copy of the CFPM Knowledge Statement attached?	YES	NO
Is a copy of the Designated Alternate Statement attached?	YES	NO
Hand Washing Facilities
Are hand washing sinks accessible and convenient to food workers in all food preparation areas, food service areas, and dish washing areas?	YES	NO
Are hand soap, paper towels, and waste receptacles supplied at all hand washing facilities? YES NO
Are all hand washing sinks provided with a mixing valve faucet?	YES	NO
Do all hand washing sinks reach a minimum of 85°F?	YES	NO
Are all hand washing sinks properly labeled with required signage?	YES	NO

Floors
Are all floor materials smooth, non-absorbent, and made of washable materials?	YES	NO
Are the floors and wall junctures coved (covered to prevent moisture from entering in)? YES	NO
Are the floors graded to the drain?	YES	NO

Walls and Ceilings
Are the wall and ceiling materials smooth, non-absorbent, and made of washable materials? YES	NO
Are the walls light in color?	YES	NO

Toilet Facilities
Are toilet facilities conveniently located?	YES	NO
Are all toilet room doors self-closing?	YES	NO
Is ventilation provided?	YES	NO
Are toilet facilities to be used by women provided with a covered waste receptacle?  YES	NO
Are toilet room hand washing facilities provided with soap, paper towel, and waste receptables? YES	NO
Are approved back flow protection devises in place (consult with plumber)?	YES	NO
Do toilet room hand washing sinks not allow for hot water to exceed 115°F maximum? YES	NO

Sewage and Liquid Waste Disposal
Is the FSE on a Public Water system?	YES	NO
Is the FSE on an On-site Septic system?	YES	NO
Is there a grease trap?  YES	NO
Size of grease trap: 	gallons
Frequency of cleaning: 	
Is it an indoor grease trap?  YES	NO
Is there an Automatic Grease Recovery Unit (AGRU)?	YES	NO
Is there an Outdoor In-Ground grease trap?	YES	NO
Water Supply
Is the FSE a Public Water supply customer?	YES	NO
Is there an On-site Well?	YES	NO
Water treatment: 	
Plumbing
Are dishwashing machines, garbage disposals or any other equipment connected to the water supply in such a manner to prevent backflow (consult with a plumber)?	YES	NO
Are dishwashing machine waste lines indirectly connected to the sewer?	YES	NO
Are there any exposed overhead sewer lines in food preparation or food storage areas?
YES	NO	If yes, describe shielding: 	
Are carbonators equipped with proper backflow protection (refer to soda company)? YES	NO

Lighting
Is adequate lighting provided in all areas of the establishment?  YES  NO
Are all light fixtures properly covered with safety shields and caps or are shatter proof bulbs installed in all food preparation areas, display areas, cooling units, display cases, and dishwashing areas? YES NO

Ventilation
Are hoods provided above all grease-producing cooking units (fryolators, ranges)? YES  NO
Have the necessary approvals from the Fire Marshall been granted?	YES	NO
How will the hood ventilation system be cleaned?

Refrigeration
Approximately how many meals will you serve on your busiest day? 	
How many cubic feet of refrigerated storage will you have? 	
How many square feet of walk-in cooler storage will you have? 	
How many cubic feet of freezer storage will you have? 	
How many square feet of walk-in freezer storage will you have? 	
Do refrigeration units maintain food at 41°F or below?	YES	NO
Are all refrigeration units equipped with accurate thermometers?	YES	NO

Storage Areas
How many square feet of dry storage area will you have? 	

Are racks and shelves raised 12 inches or more above the floor?  YES  NO
Are shelves smooth, cleanable, and made of durable materials?	YES	NO
Are toxic/poisonous materials properly stored and labeled in a designated area separate from food?
YES	NO

Insect and Rodent Control
Are all outer openings protected against entry of insects and rodents by use of doors, screens, fans, etc.?	YES	NO
Are all outer doors self- closing?	YES	NO
Are all openings in floors, walls, ceilings, cables, etc., properly caulked or protected? YES NO

Equipment
Are all equipment, storage containers, and food preparation utensils made of food grade materials?
YES	NO
Is equipment sealed to the floor and walls where necessary, or moveable or on legs to enable cleaning? YES NO
Are sneeze guards provided where applicable (salad bars, buffets, etc.)?  YES  NO

Sinks and Ware Washing
Does the plan include a food preparation sink?  YES  NO
Are pots, pans, dishes, etc., to be washed in sinks and/or dishwashing machine?
Dishwasher
3 Bay Sink
Both
If using 3 bay sink, does the largest pot and pan fit into the compartment of the sanitizer sink? YES	NO
Are there drain boards on either side of the 3 bay sink?	YES	NO
What facility is there for air drying of washed wares?

Check the types of sanitizers used:
Dishwashing Machine	3 Bay Sink	Food-Contact Surfaces	
Chlorine
Quaternary Ammonium
Iodine
Booster Heater	Chlorine
Quaternary Ammonium
Iodine
Booster Heater	Chlorine
Quaternary Ammonium
Iodine
Booster Heater	
Are the approved test strips available for checking chemical sanitizer concentration?	YES NO
Provide Name and Model # of dishwasher (if applicable):

Do dishwashers have temperature and pressure gauges as required that are accurately working? YES	NO
Provide Name and Model # of booster heater:

Is there a mop sink?	YES	NO	If no, describe facility for cleaning mops and other equipment and disposing of floor washing water:

Garbage
Is there an area designated for garbage disposal outside of the facility?	YES	NO
Does the garbage disposal area have a paved base?	YES	NO
Do all containers have lids?	YES	NO
Is there an area designated for garbage can and floor mat cleaning?	YES	NO

Ice and Hot Water
How will ice be provided?
On site ice machine
Purchased. From where? 	
Both
What is the capacity of the hot water heater? 	 BTU/hour

Amanda Gonzalez
2024-07-03 15:37:18
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Step 3 Forms
Certified Food Protection Manager Demonstrated Knowledge Statement
Pursuant to Public Health Code (PHC) Section: 19-13-B42(s)(6), 19-13-B48U)(5), 19-13-B49(t)(5), in the absence of documentation that the Certified Food Protection Manager (CFPM) has passed a test administered by a testing organization approved by the department, a signed statement must be provided by the owner/operator of the food service, itinerant food vending or catering food service establishment (as applicable), attesting that the CFPM has demonstrated knowledge of food safety as specified below:

Elements of knowledge

Identify foodborne illness - define terms associated with foodborne illness; recognize the major microorganisms and toxins that can contaminate food and the problems that can be associated with the contamination; define and recognize potentially hazardous foods; define and recognize illness that can be associated with chemical and physical contamination; define and recognize the major contributing factors for foodborne illness; recognize how microorganisms cause foodborne disease.

Identify time/temperature relationship with foodborne illness - recognize the relationship between time/temperature and microorganisms (survival, growth, and toxin production); describe the use of thermometers in monitoring food temperatures.

Describe the relationship between personal hygiene and food safety - recognize the association between hand contact and foodborne illness; recognize the association between personal habits and behaviors and foodborne illness; recognize the association between health of a food handler and foodborne illness; recognize how policies, procedures and management contribute to improved food hygiene practices.

Describe methods for preventing food contamination from purchasing to serving - define terms associated with contamination; identify potential hazards prior to delivery and during delivery; identify potential hazards and methods to minimize or eliminate hazards after delivery.

Identify and apply correct procedures for cleaning and sanitizing- equipment and utensils- define terms associated with cleaning and sanitizing; apply principles of cleaning and sanitizing; identify materials, equipment, detergent, sanitizer; apply appropriate methods of cleaning and sanitizing; identify frequency of cleaning and sanitizing.

Recognize problems and potential solutions associated with facility equipment and layout - identify facility, design, and construction suitable for food service establishments; identify equipment and utensil design and location.

Recognize problems and potential solutions associated with, temperature control, preventing cross contamination, housekeeping, and maintenance - implement self- inspection program; implement pest control program; implement cleaning schedules and procedures; implement equipment and facility maintenance program.

Identify and recognize the foods most commonly associated with food allergies.

Demonstrable elements of competency
Assess the potential for foodborne illness in a food service establishment - perform operational food safety assessment; recognize and develop standards, policies, and procedures, select and train employees; implement self-audit/inspection program; revise policy and procedure (feedback loop); implement crisis management program.

Assess and manage the process flow- identify approved source; implement and maintain a receiving program; implement and maintain storage procedures; implement and maintain preparation procedures; implement and maintain holding/service/display procedures; implement and maintain cooling and post preparation storage procedures; implement and maintain re-service procedures; implement and maintain transportation procedures.

I 		, attest that 	 (Print Name of Owner or Operator)		(Print Name of Certified Food Protection Manager)
is employed in a full-time supervisory position and has demonstrated to me the elements of knowledge and demonstrable elements of competency as described in A and B, as listed above.

Signature and Title		Date:  / /	 (Signed by Owner/Operator of the Establishment)

Signature and Title: 		Date:  / /	 (Signed by Certified Food Protection Manager)

Name of Establishment:	

Address of Establishment:	

Alternate in Charge Demonstrated Knowledge Statement
Pursuant to Public Health Code (PHC) Section: 19-13-B42(s)(8)(B) and 19-13-B49(t)(7)(B), the owner or manager of the food service/catering food service establishment shall designate an alternate person who has demonstrated the elements of knowledge and competency listed below, as per PHC Section 19-13-B42(s)(6), 19-13-B49(t)(5), to be in charge at all times when the qualified food operator cannot be present.

The alternate person in charge shall be responsible for ensuring that all employees comply with the regulations and that food is safely prepared; handling emergencies; admitting the inspector; and receiving and signing the inspection report.

A signed statement must be provided by the owner/operator of the food service or catering food service establishment (as applicable), attesting that the alternate person in charge has demonstrated knowledge of food safety as specified below:

Elements of knowledge
Identify foodborne illness - define terms associated with foodborne illness; recognize the major microorganisms and toxins that can contaminate food and the problems that can be associated with the contamination; define and recognize potentially hazardous foods; define and recognize illness that can be associated with chemical and physical contamination; define and recognize the major contributing factors for foodborne illness; recognize how microorganisms cause foodborne disease.
Identify time/temperature relationship with foodborne illness- recognize the relationship between time/temperature and microorganisms (survival, growth, and toxin production); describe the use of thermometers in monitoring food temperatures.

Describe the relationship between personal hygiene and food safety - recognize the association between hand contact and foodborne illness; recognize the association between personal habits and behaviors and foodborne illness; recognize the association between health of a food handler and foodborne illness; recognize how policies, procedures and management contribute to improved food hygiene practices.

Describe methods for preventing food contamination from purchasing to serving - define terms associated with contamination; identify potential hazards prior to delivery and during delivery; identify potential hazards and methods to minimize or eliminate hazards after delivery.
Identify and apply correct procedures for cleaning and sanitizing equipment and utensils - define terms associated with cleaning and sanitizing; apply principles of cleaning and sanitizing; identify materials, equipment, detergent, sanitizer; apply appropriate methods of cleaning and sanitizing; identify frequency of cleaning and sanitizing.

Recognize problems and potential solutions associated with facility equipment and layout- identify facility, design, and construction suitable for food service establishments; identify equipment and utensil design and location.

Recognize problems and potential solutions associated with, temperature control, preventing cross

contamination, housekeeping, and maintenance - implement self-inspection program; implement pest control program; implement cleaning schedules and procedures; implement equipment and facility maintenance program.

Identify and recognize the foods most commonly associated with food allergies.

Demonstrable elements of competency

Assess the potential for foodborne illness in a food service establishment - perform operational food safety assessment; recognize and develop standards, policies, and procedures, select and train employees; implement self-audit/inspection program; revise policy and procedure (feedback loop); implement crisis management program.

Assess and manage the process flow - identify approved source; implement and maintain a receiving program; implement and maintain storage procedures; implement and maintain preparation procedures; implement and maintain holding/service/display procedures; implement and maintain cooling and post preparation storage procedures; implement and maintain re-service procedures; implement and maintain transportation procedures.

I 		attest that 	 (Print Name of Owner or Operator)		(Print Name of Certified Food Protection Manager)
is employed in a full-time supervisory position and has demonstrated to me the elements of knowledge and demonstrable elements of competency as described in A and B, as listed above.

Signature and Title		Date:  / /	 (Signed by Owner/Operator of the Establishment)

Signature and Title: 		Date:  / /	 (Signed by Certified Food Protection Manager)

Name of Establishment:	

Address of Establishment:	

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 PLAN REVIEW APPLICATION

Type of Application: □ New  □ Renovation/Remodel  □ Change of Ownership
Project Start Date:   /  /	 Projected Completion Date:   /  /	

Food Service Establishment Name (not LLC): 	

Physical Address: 	

City:	State:	Zip:	
Billing Address: 	

City:	State:	Zip: 	

Phone:	Fax:	Billing Email: 	
Owner of Establishment (LLC): 	

Home Address:	City:	State:	Zip: 	

Primary Phone:	Primary Email: 	

Manager/Operator Name:	

Primary Phone:	Primary Email: 	
Certified Food Protection Manager (CFPM):
Name:	Primary Phone: 	
Designated Alternate CFPM:
Name:	Primary Phone: 	

Type of Food Operation (select all that apply):
Food Service Establishment		Grocery	Convenience Store	Bakery Bar	Daycare Center Brewery/Distillery/Winery	Long Term Care School	Soft Serve Ice Cream	Deli	Caterer
□Mobile Unit □Other: 	

Classification (review definitions):
□ Class 1  □ Class 2  □ Class 3  □ Class 4
Operational Period (review definitions):
□ Year-Round  □ Seasonal (less than 6 months per Calendar Year)
Hours of Operation:
□ Sun: 	 □ Mon: 	 □ Tue: 	 □ Wed: 	 □ Th: 	 □ Fri: 	 □ Sat: 	
Restaurant Seating Capacity:
# of Indoor Seats: 	 # of Outdoor Seats: 	 Facility Size (sq. ft.): 	sq. ft.
Water Supply:
□ Public Water  □ Well Water  Last date tested   /  /	 (attach copy of water results)
Sewage Disposal:
□ Public Sewer  □ Septic System  Last date pumped   /  /	
Grease Disposal:
□ Automatic Grease Recovery Unit (AGRU) □ Outdoor In-Ground Grease Trap

NDDH Use Only
Class:	1	2	3	4	Type:	FSE	Itinerant	Non-Com.	Seasonal	# of Inspections: 	
Food Service Permit Fee: $	 Date:   /	/		Check #: 	 CC	E-Check	Cash	Receipt #: 	
Restaurant Plan Review Fee: $	 Date:   /	/	 Check #: 	 CC E-Check	Cash	Receipt #: 	

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 food 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 food 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: 		Food Service Classification:  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

OFFICE USE ONLY:
Date Updated - EHS Database: 	
Date Updated – Excel Sheet:		

Initials:	
Initials:	

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

Rev. 110117 (P:\HAN\FORMS)

*This page is only submitted once a pre-operational inspection from NDDH has been completed*

Food Service Establishment Name (not LLC):

Physical Address: 	

Signature Section:
Your Name (print): 	
Signature: 		 Date:  / /  Building: 	  Date:  / /  Zoning: 	 Date:  / /   Fire: 		  Date:   /  /   
Water Commissioner: 	 Date:   /  /    (if using public sewer)
NDDH Sanitarian: 	 Date:   /  /   

Resources
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.
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, a private residential dwelling in which food is prepared under section 21a-62a or a food manufacturing establishment, as defined in section 21a-151.
Food establishment classifications:
Class 1 food establishment: means a retail food establishment that does not serve a population that is highly susceptible to food borne illnesses and only offers (A) commercially packaged food in its original commercial package that is time or temperature controlled for safety, or (B) commercially prepackaged, precooked food that is time or temperature controlled for safety and heated, hot held and served in its original commercial package not later than four hours after heating, 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 or cooked and served immediately, or that prepares or 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) offers food that is time or temperature controlled for safety and requires 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.
Bakery: baked and prepared goods, excluding retail sales.

Bed and breakfasts: may use a home kitchen as long as the total number of individuals served does not exceed 12 (this includes the owner and other individuals provided with overnight accommodations). The operation is restricted to a total of 12 individuals for BREAKFAST only. The operation is restricted to cooking potentially hazardous foods for immediate on-site service only. Potentially hazardous foods shall not be cooked several

hours or days before service. Only non-potentially hazardous foods that have not gone out to the tables can be used as leftovers.

Food stores: a grocery or convenience store with no food preparation or consumption.

Itinerant vendor: a mobile unit required to have a hand-washing sink with hot and cold water under pressure, holding tank, and mechanical refrigeration. A certified water sample is also required.

Push carts: exempt from the itinerant vendor requirements but limited to the sale of hot dogs and pre-packaged foods only.

Seasonal: a food service establishment or food store open for six months or less at the same geographical location.

Simple Transfer of Ownership Form:
You may apply for a Simple Transfer of Ownership if the answer to these five questions is NO.
Are you proposing any renovations or remodeling to the existing facility? YES NO
Are you proposing or planning to add or change any equipment? YES NO
Are you proposing any changes to the existing establishment menu? YES NO
Will you be changing the hours or days of operation? YES NO
Will you be adding any new seating (indoor or outdoor) at the establishment? YES NO

If you answered NO to all five questions you do not need to complete this application and instead need to complete and submit the FSE Simple Transfer of Ownership Form at nddh.org on our Forms and Permits page under Food Service.

Supermarkets: a full-service supermarket with different departments such as deli and seafood.

ANAB-CFP Accreditation Program (Accredited)

#	Organization	ID	
1	National Restaurant Association Solutions
ServSafe® Food Protection Manager Certification Program	0655	
	Local in person trainings are held at Click and NDDH (visit the CFPM page at nddh.org for more info.)		
2	AAA Trainers Inc. (DBA: AAA Food Handler/1 AAA Food Handler)
Certified Food Protection Manager	9160	
3	APS Culinary Dynamics (DBA: World Food Safety Organization) WFSO-USA Food Protection Manager	9129	
4	Certus/StateFoodSafety
StateFoodSafety Certified Food Protection Manager (CFPM) Exam	1020	
5	DSBWorldWide, Inc (DBA: EduClasses®) FMC® Food Managers Certification	1135	
6	Learn2Serve
Learn2Serve® Food Protection Manager Certification Program	0975	
7	My Food Service License Certified Food Protection Manager	9154	
8	National Registry of Food Safety Professionals Food Protection Manager Certification Program International Certified Food Safety Manager	0656	
9	Relish Works, Inc. (DBA: Trust20) Food Protection Manager	9065	
10	Responsible Training / Safeway Certifications, LLC Food Protection Manager Certification	1042	
11	The Always Food Safe Company, LLC Food Protection Manager Certification	1203	

Food Licensing and Registration

CT Department of Consumer Protection

You may apply online for all food and beverage licenses Online Initial Application Instructions

If you prefer, you may complete and mail in a paper application instead.
Apple Juice & Cider Mfr.	Paper application	Reinstatement application	
Bakery	Paper application	Reinstatement application	
Cottage Food Operation	Paper application		
Egg Distributor	Paper application		
Item Price Exemption	Paper Application		
Food Mfg. Establishment	Paper application License Requirements	Reinstatement application	
Food Warehouse Registration	Paper application	Reinstatement application	
Frozen Dessert Retailer	Paper application	Reinstatement application	
Frozen Dessert Wholesaler	Paper application		
Non-Alcoholic Beverage Mfr.	Paper application Water Analysis Form	Reinstatement application	
Vending Machine Operator	Paper application		

For questions about any food or beverage license or registration, please contact the Food and Standards Division at dcp.foodandstandards@ct.gov.

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM CLASSIFICATION NOTIFICATION FORM
This form may be used to notify the Department of Public Health (Department) of the following circumstances:
A change in the classification of a Public Water System;
An activation and the classification of a Public Water System; and,
The classification of a Public Water System or Non-Public Water System with respect to a proposed real estate development.

Do not use this form to petition the Department for a Declaratory Ruling. A declaratory ruling is a legal proceeding, in which a person may request the Department to determine the validity of any regulation or the applicability of any regulation, statute or final decision under the Department’s jurisdiction to specific circumstances. Connecticut General Statues (CGS)
§ 4-176. See Regulations of Connecticut State Agencies (RCSA) §§ 19a-9-10 and 19a-9-12. Any request to determine the classification of a proposed or existing public water system shall conform with the requirements in RCSA § 19a-9-6(a). RCSA § 19a-9-12.
If you are water company, as defined in CGS § 16-262n and intend to cease your operations or discontinue the provision of water service to customers, do not use this form. See CGS § 16-46 governing the dissolution and termination of such services.

Section 1: Property Owner Contact Information	
Owner of Property	Legal Contact Person (if owner is not an individual)	
Owner Mailing Street Address	City	State	ZIP Code	
Owner Telephone Number	Owner Email Address	
Section 2: Property Information	
Property Street Address	City	State	
Business(es) Operating on the Property (if applicable)	
Current or Intended Use of the Property (Check all that apply):	Residential	School		Food Service	Day Care Campground	Medical/Dental	Professional Office	Youth Camp	Gas Station	Retail	Manufacturing
Place of Worship	Park/Recreation Area	Other - specify: 		
Description of Current or Intended Use of the Property (Attach additional pages, if necessary):	
Property is currently regulated as a Public Water System (PWS)?	Yes	No If yes, provide PWS ID: PWS ID#:	
Section 3: Water Source and Usage Information	
Water Source(s):
Existing Well(s)	Proposed Well(s)	Total Number of Well(s): 		
Water Usage:
How will the water be used? (check all that apply):
drinking	bathing/showering	cooking, including food preparation	dishwashing	public restroom drinking water fountain	other–specify: 			
RCSA § 19-13-B102(a)(41) defines “drinking water” to mean “water, treated or untreated, intended for human consumption, which includes drinking, bathing, showering, cooking, dishwashing and maintaining oral hygiene.”	
Water Treatment:
Is the water treated?	Yes	No
If yes, specify type(s): 	 Purpose of treatment: 		

Section 4: Population and Operational Information	
Number of Consumers/Service Connections2
(Buildings Served)	Residential	Non-Residential	
Maximum Daily Population Served1
(Enter Number)
Existing Maximum Daily Population:		
Proposed Maximum Daily Population:		 Proposed Population Start Date:			Number of days per year facility
is/will be operational:	Typical Annual Operating Period	
		Start Month/Day	End Month/Day	
Section 5: Notification to DPH	
Part I: Public Water System Notification
I am notifying the Department that my Property serves or will serve (once constructed) water to the public as follows:
(Check only one option below for Part I)
The Property is a Public Water System (PWS) because the water system on the property serves or will serve 25 or more people or 15 or more consumers daily at least 60 days of the year (continue to Part II)

The Property is a Non-Public (NP) Water System because the water system does not serve or will not serve 25 or more people or 15 or more consumers daily for more than 60 days per year OR the system serves or will serve 25 or more people or 15 or more consumers daily for more than 60 days per year and the system meets all of the following conditions (check all that apply):
Consists only of distribution and storage facilities;
Does not have any treatment facilities, other than those for non-potable use;
Obtains all of its water from, but is not owned or operated by, a public water system;
Does not separately bill the consumers for water use or consumption; and
Is not a carrier which conveys passengers in interstate commerce;
Part II: Public Water System Classification Notification
If Public Water System (PWS) was selected in Part I, check only one option below.
I am notifying the Department that my Property’s current or proposed Public Water System is classified as follows:

The Property is a Community Public Water System because the public water system on the property serves or sill serve 25 or more year-round residents. See RCSA § 19-13-B102(a)(16).
Examples: Apartment/Condominium Complexes, homeowners’ associations, single family home developments served by a single or combined well system.

The Property is a Non-Transient Non-Community (NTNC) Public Water System because the public water regularly serves or will serve at least 25 of the same persons over 6 months per year and it is not a community system. See RCSA § 19-13-B102(a)(87).
Examples: Childcare facilities, schools and larger employers/businesses.

The Property is a Transient Non-Community (TNC) Public Water System because the public water system serves or will serve at least 25 persons daily at least 60 days per year and is not a non-transient non-community water system. See RCSA § 19-13-B102(a)(128).
Examples: Restaurants, parks, campgrounds, gas stations, youth camps, plazas or places of worship without a school or daycare.	
Additional Comments:	
Pursuant to CGS § 53a-157b, I certify to the best of my knowledge that the information is provided in this form is complete and correct.

Signature of Property Owner/Legal Contact: 		Date: 	

Printed Name of Property Owner/Legal Contact: 		
1 Population served shall be based on design population pursuant to RCSA 16-262m-8(a)(3).
2 “Consumer” means any private dwelling, hotel, motel, boardinghouse, apartment, store, office building, institution, mechanical or manufacturing establishment or other place of business or industry to which water is supplied by a water company.
Please submit completed forms and all supporting documents to: DWDCompliance@ct.gov
And to your Local Health Department, which may be found here.

NDDH Use Only
File #:	

B51d/Change in Use Fee: 	

Receipt # 	 Cash: 	 Check # 	 Credit Card:	 Date: 	

Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone - 860-774-7350 / Fax - 860-774-1308
Web: www.nddh.org Email: email@nddh.org
B100a /Change in Use Application
To conform to PHC 19-13-B100a – Building Conversions/Changes in Use, Building Additions,

Street #: 	 Street: 			 Town: 		 Assessor’s Map: 		 Block: 	 Lot: 	Dev. Lot : 	 Lot Size: 	

Garages/Accessory Structures, Swimming Pools, Sewage Disposal Area Preservation (See Reverse Side for Instructions.)
Legal Owner: 	
Mailing Address: 	
Town: 	 State: 	 Zip: 	
Work Phone: 	 Home Phone:			Cell Phone:	 Email Address: 					 Year Built: 			No. of Bedrooms: 	 Description of proposed change/addition:				

Agent for Owner: 			 Agent’s Mailing Address: 			 Town: 	 State: 	Zip: 	
Agent’s Phone Number: 	Email:	

************************************************************************************* PROPERTY OWNER: By signing above, you certify that the information provided is a true and accurate description of the addition, accessory structure, or pool. No services will be rendered until payment is received. Do not fax, return by mail. In the event of application withdrawal by the applicant, NDDH reserves the right to retain a non-refundable processing fee. (If working on behalf of owner, please attach signed Letter of Consent)

Signature of Legal Property Owner	Date
*************************************************************************************

B100a / Change in Use Application INSTRUCTIONS
This form is used to conform to the State of Connecticut Public Health Code, Section 19-13- B100a, which governs building conversions and/or changes in use to existing structures, building additions, garages/accessory structures, swimming pools and sewage disposal area preservation.

You are filling out this form to provide the local health department with important information to assure that you:
Do not build any structures on top of an existing septic system
Conform to the required separating distances and maintain your property according to the Connecticut Public Health Code

In addition to filling out this form, you will also have to submit the following with your application:
If your home was built prior to 1985, please have your deed or the previous owners name available. This information can be obtained from your Town Clerk.
A plot plan drawn to scale (Example: 1inch = 20 feet) which shows the location of the house, well, sewer line, and closest property lines. Be sure to indicate distances between each item.

□
□

A written description of the proposed addition, accessory structure or pool.

If proposing an addition to an existing structure, please provide a sketch of the
existing floor plan and a sketch of the proposed floor plan change.

Exemptions
You are not required to file a B100a Application for the following:
Accessory buildings or sheds less than 200 square feet which will sit directly on pressure treated plywood or concrete blocks and do not require the pouring of a concrete slab, frost protected footings, sonar tubes or any other foundation that would disturb the soil.
Anchoring kits that prevent uplift due to winds which are used for temporary structures like removable carports. Anchors should not penetrate the septic system. (Please note, anchoring kits that require the pouring of a concrete slab or permanent footings do require a B100a application.)
In the event of application withdrawal by the applicant, NDDH reserves the right to retain a
non-refundable processing fee.

In order to avoid unnecessary delays, please be sure to complete the form in its entirety and submit all required information and fees. Do not fax, return by mail.
For additional assistance, please contact us:
Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234