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
SERVICE APPLICATION
COSMETOLOGY: 	 BARBER: 	 NAIL SALON: 	 OTHER: 	

Name of Establishment: 	

Business Street Address: 	 Town: 	

Legal Owner of Business: 	

Billing Email: 	

Mailing Address for Business: 	

Town: 	 State: 	 Zip: 	 Business Tel:	

Manager Name: 	
Mailing Address: 	
Town: 	 State: 	 Zip: 	 Tel: 	 Fax: 	

Number of Workstations/Chairs: 	 Business Hours: 	

Sewage Disposal: Public: 	 Private: 	 Date Last Pumped: 	

Water Supply: Public: 	 Private: 	 Date Last Tested: 	

**************************************************************************** List all operators below including name, license type, and license number with expiration date. (Attach additional sheets if necessary)

Signature of Owner/Operator:	Date: 	

Name:	Type of License:	License Number:	Employee or Independent
Contractor

NDDH Use Only		
Date: 	 Fee: 	 Check # 		CC  E-Check	Cash	Receipt #		
Date: 	 Fee: 	 Check # 		CC  E-Check	Cash	Receipt #		
Rev. 111022