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 - INDEPENDENT CONTRACTOR
COSMETOLOGY_____ BARBER ______ NAIL TECH _____
EYELASH TECH _____ DAY SPA _____ OTHER _____

Independent Contractor Name: ____________________________________________________
Mailing Address (not salon address): __________________________________________________________
Town: ________________________ State:____________________ Zip Code: ______________        
Telephone #: _____________________Billing Email:  _________________________________
Number of Workstations/Chairs: 	_____ Business Hours: ______________________
Department of Public Health License type: _____________   License #:____________________
Expiration Date: ________________________________________________________________

Independent Contractor must fill out this section of the application.

Establishment Name:_______________________  Legal Owner of Business:________________
Establishment Physical Address: ____________________________________________________
Town: ____________________       State:__________________    Zip Code: ________________        
Mailing Address (if different from physical address:_____________________________________________
Business Telephone #:	______________________ Fax #: _______________________________

NDDH Use Only

File/ID # __________________________ Fee: _______________ Date: ______________

Late/Penalty/Other Fee: Check # _________________     CC     E-Check     Cash     Receipt #_______________   

Independent Contractor’s Signature:                                                           	Date: _____________ 

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

NDDH Use Only

File/ID # __________________________ Fee: _______________ Date: ______________

Late/Penalty/Other Fee: Check # _________________     CC     E-Check     Cash     Receipt #_______________   

NDDH Use Only

File/ID # __________________________ Fee: _______________ Date: ______________

Late/Penalty/Other Fee: Check # _________________     CC     E-Check     Cash     Receipt #_______________