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Public Health Certificate - Connecticut

Public Health Certificate Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide .
 Fillable pdf Last Modified 11/24/2008
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DCPLC-HEALTH Rev 5/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 713-7235 Website: http://www.ct.gov/dcp PUBLIC HEALTH CERTIFICATE I CERTIFY THAT: __________________________________________________________________________ NAME OF PERMITTEE __________________________________________________________________________ NAME OF ESTABLISHMENT __________________________________________________________________________ STREET __________________________________________________________________________ TOWN or CITY and ZIP CODE COMPLIED WITH THE REQUIREMENTS OF THE STATE PUBLIC HEALTH CODE ON PLACES DISPENSING FOOD AND BEVERAGES AT THE TIME OF INSPECTION. X________________________________________________________ Signature Of Health Director Or His Agent ____________________ Date American LegalNet, Inc. www.FormsWorkflow.com
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