Salon 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

Salon Review Checklist
STEPS 1 & 2 ARE REQUIRED TO SUBMIT THE APPLICATION
(checklists with an * include a required document)
Step 1 – Sewage Disposal and Water Supply (public or private):
If on public sewer in Brooklyn or Killingly, provide letter from WPCA regarding status*
If on private septic
Complete and submit a File B* (new construction, repair, or soil testing) with consent form or B-100a* (change in use) with consent form
If on public water:
Submit a copy of the last water bill*
If on private well:
Submit Public Water System Screening Form* (form in resource section pgs. 10 and 11)
Fill out all application information up until Section 5: For Local Health Use Only
Submit a copy of water test results*
Verify all zoning requirements have been approved by local Planning & Zoning Departments

Step 2 – Review, sign, and submit the following:
Submit copy of service license*
Submit the floor plan* drawn to scale
Submit Service Application and Emergency Contact pages 8 and 9*
Page 7 (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 listed on Fee Schedule
Step 3 – A plan review approval letter will be sent once steps 1 & 2 are complete, if applicable. You must then:
Submit any additional requirements per the plan review approval letter, if applicable
Submit payment for Annual Permit Fee 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 7 of the Salon Plan Review Application*

Purpose Statement
The Northeast District Department of Health (NDDH) requirements for a salon establishment are based on the General Statutes Ch. 386 Secs. 20-234 to 20-249, Ch. 387 Secs. 20-250 to 20-266m, CT Regulations (Public Health Codes) 19-13-B101, B102, B103a-f, Public Act 117, Section 196(b), CT DPH Salon Inspection Form Guidelines, and the NDDH Salon Ordinance. The intent of the Salon Plan Review is to educate and enforce sanitary conditions and infection controls to reduce the occurrence and potential spread of communicable diseases. An NDDH sanitarian will review the application and work with you to ensure your establishment is code complaint.
Salon establishments include any place where services are provided to the public. Establishments include, but are not limited to cosmetology, barbershops, hair salons, nail salons, and day spas.
Without an FSE (food service establishment) permit, you cannot serve any food or drinks to the public at your establishment and only self-serve areas with drinks and snacks are allowed. We encourage disclosure signage regarding allergies be posted in conspicuous areas for customer viewing.

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.

Changes may occur in the CT General Statutes and Public Health Code (Regulations). Approval of this plan does not mean that the establishment specified will be exempt from compliance with future code requirements.
A permit is required to open and annual permit renewals are required to continue operations.

When the plan and facility are approved and applicable fees have been paid, NDDH will issue a salon permit for the establishment that will expire at year’s end. Renewals are due to NDDH by
December 15th annually for the following permit year.

NDDH requires owners to complete the Salon Plan Review for any proposed establishment including new businesses, renovations, and operational changes. Your signature on the application constitutes your agreement to comply with the requirements for salon establishments.

Step 1 & 2 Requirements and Resources
Sewage Disposal and Water Supply
Private sewage disposal system (septic)
File B Application (is for new construction, repairs, and soil testing)
B100a Application (is for change in use)
Private water supply (well)
Public Water System Screening Form*
This form is required by CT DPH when a private well will be used for public consumption
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 below.
Show the location of all stations and equipment. Each piece should be clearly labeled.
Clearly designate adequate handwashing sinks in the service area 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 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 and exits.
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.
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 mop sink or curbed cleaning facility with facilities for hanging wet mops.
Cabinets for storing toxic chemicals.
Dressing rooms, locker areas, employee rest areas, and/or coat rack as required.
Site plan, if applicable.
Surface Finish Schedule
The form is provided below.
All reusable equipment must be constructed of hard materials with smooth non-porous surfaces as detailed in the CT DPH Salon Inspection Form Guidelines.
Pre-Operational Questionnaire
This questionnaire assists the NDDH Sanitarian in reviewing the details of the submitted plan.
Salon Employees and Independent Contractors
Salons are permitted to the permit holder based on their license.
Employees are staff who are permitted under the permit holder/salon inspection.
Independent Contractors are not employees and are permitted separately (rent space from the owner).

Floor Plan for:

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

																																			

Use this key or provide another clear key.	Scale: 1 square=	ft.
Hand Sink	HS							
Utility Sink	MS							
Prep Sink	PS							
Salon Station	SS							
Table	Tbl							
Countertop	Ctr							

								

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

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

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

STATION 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: 	

Floor Plan
Is an accurate to scale floor plan attached?  YES	NO
Hand Washing Facilities
Are hand washing sinks accessible and convenient to workers in all service 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 Salon on a Public Water system? YES	NO
Is the Salon on an On-site Septic system? YES	NO
Water Supply
Is the Salon a Public Water supply customer? YES	NO
Is there an On-site Well?	YES	NO
□	Water treatment: 	
Is a water test provided, if on private well? YES  NO
Is a copy of the water bill provided, if on public water? YES  NO

Plumbing
Are sinks, wash stations, or any other equipment connected to the water supply in such a manner to prevent backflow (consult with a plumber)?	YES	NO

Lighting
Is adequate lighting provided in all areas of the establishment?  YES  NO

Ventilation
Are there properly functioning vents in the bathrooms? YES	NO
Have the necessary approvals from the Fire Marshall been granted? YES NO

Storage Areas
Are shelves smooth, cleanable, and made of durable materials?	YES	NO
Are toxic/poisonous materials properly stored and labeled in a designated area? 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

Sinks
Does the plan include a service area sink?  YES  NO
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
What is the capacity of the hot water heater? 	 BTU/hour

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

Salon 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: 	/	/	

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: 	CT Water #:			
**************************************************************************** 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

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: 			 24/7 Contact #: 		Cell Number: 				 Work Phone: 	Fax Number: 			 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 12/16/21

9

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.