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

Seasonal Farmers Market Food License Application Vendor / Farm Name: 	 Location of Markets Attending:
 Brooklyn  Canterbury  Eastford  Hampton  Killingly  Plainfield  Pomfret  Putnam  Sterling  Thompson  Union  Woodstock

Season Start Date: 	Season End Date: 	Operation Times: 	 Are you a non-profit? Yes  No  If so, tax exempt #: 		
Contact Person (applicant):
Name: 	Phone #:		Email: 				 Mailing Address: 		City: 		ST:	Zip:	 Name of CFPM or FAST Class trained person: 					
Please list all items on the proposed items for sale:

Food Storage/Disposal:
How will foods be stored at proper temperatures:
Hot: 		 Cold: 	 Method of gray water disposal: 			 What are your transportation methods (if applicable): 		 
Currently Permitted by:
 Dept of Consumer Protection: Permit #: 	Expiration Date: 	
 Dept of Agriculture: Permit #: 	Expiration Date: 	
 USDA: Name of package plant: 	Permit #: 	Exp. Date: 	
Water Supply:
Public Water: 	Bottled Water: 	Private Well: 	
NOTE: If using water from a private well, a water test conducted within the last year must be on file with NDDH prior to the issuance of a permit.

Facilities Info: Portable Toilets:  Yes No	Facility Name: 	
Applicant Name: 	Applicant Signature: 	Date: 	

Approving Sanitarian: 		Date: