Establishment
Establishment Address *
Establishment Address
Phone *
Phone
Fax
Fax
Owner
Name *
Name
Owner Address *
Owner Address
Management
Name of Operator/Manager *
Name of Operator/Manager
Phone *
Phone
Section 3
Emergency Contact *
Emergency Contact
Phone *
Phone
QFO
Name of Qualified Food Operator (QFO) *
Name of Qualified Food Operator (QFO)
Required for Class 3 and 4 establishments. Please attach a copy of QFO certificate.
Classification of Food Establishments
Classification of Food Establishments per the State of CT Public Health Code Class I: means a food establishment that only offers for retail sale (A) prepackaged food that is not time or temperature controlled for safety (B) commercially processed food that (i) is time or temperature controlled for safety and heated for hot holding, but (ii) is not permitted to be cooled (C) food prepared in the establishment that is not time or temperature controlled for safety Class 2: means a retail food establishment that does not serve a population that is highly susceptible to food-borne illnesses and offers a limited menu of food that is prepared, cooked and served immediately, or that prepares and cooks food that is time or temperature controlled for safety and may require hot or cold holding, but that does not involve cooling Class III: means a retail food establishment that (A) does not serve a population that is highly susceptible to food-borne illnesses and (B) has extensive menu of foods, many of which are time or temperature controlled for safety and require complex preparation, including, but not limited to , handling of raw ingredients, cooking, cooling and reheating for hot holding Class IV: means a retail food establishment that serves a population that is highly susceptible to food-borne illnesses, or that conducts specialized food processes, including, but not limited to, smoking, curing or reduced oxygen packaging for the purposes of extending the shelf life of the food
Requests
FEE WAIVER REQUESTED: applies to State of CT owned and operated facilities; Health District member towns, their departments and facilities including public schools that are not contracted out to a for-profit vendors. NOT-FOR-PROFIT STATUS REQUESTED: (50% of fee listed above applies) The above organization is operated by a non-profit organization exempt from federal taxes AND exempt from local real estate and personal property tax. IRS and/or State of CT Department of Revenue Services determination letter(s) MUST be submitted with this application.
New Late Fee for all Annual Licenses
EFFECTIVE 7/1/17 $50 late fee Renewal received withing 30 days of license expiration $100 late fee Renewal received within 31 to 60 days of license expiration Reinstatement Fee double license fee After 60 days non-renewal, revoke licensure