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
TEMPORARY FOOD LICENSE APPLICATION
PLEASE NOTE: Applications are due 10 business days prior to the event and any application received less than 5 business days prior to the event is subject to a late fee
Event
Name of Organization Applying for Permit: 	

Title of Event: 					  Location of Event: 						 Street Address: 			 Town: 				 Type of Facility, e.g. Church, Food Booth, Food Cart, etc. 		 Start Date: 	 End Date: 	 Operation Times: 		  Is the above organization a non-profit? Yes □ No □ If so, tax exempt #	 Food Trucks Only: Are you permitted under another Health Depart.?* Yes □ No □
*Please provide a copy of the latest Food Truck Inspection and copy of current permit
Contact Person (applicant or manager of event):

Name: 	 Email: 			Phone:	 Mailing Address: 		City:	ST:  Zip:	 CFPM cerftied or FAST trained staff person overseeing the event:
(COPY OF CERTIFICATE MUST BE ATTACHED TO APPLICATION)
Name: 		 Phone(C): 			 Phone (H): 	 Phone (W): 		 Signature: 			 Date: 		
Please list all items on proposed menu:

Please Complete Reverse Side

Anticipated number of people to be served: 	

Food Storage/Disposal:

How will foods be stored at the proper temperatures:
Hot Holding: 		  Cold Holding: 	 Method of grease disposal: 		 What are your transportation methods (if applicable): 		

What/who is your food source? 	 What are your overnight storage methods? 	 Handwashing station is required (describe set up): 	

Water Supply: Public	 Private Well	 Other	 Date water last tested: 	
NOTE: PRIOR TO ANY PERMIT BEING ISSUED, A CURRENT WATER TEST (WITHIN ONE YEAR) MUST BE ON FILE IN THIS OFFICE.

V. Please list the names of all volunteers:

NDDH Use Only:	Class: 1	2	3	4	CC	E-Check	Cash
Food Service Permit Fee: 	 Receipt #	 CK#	 Date	/	/	

Late/Penalty/Other Fee: 	 Receipt #	 CK#	 Date	/	/