DCPLC-HEALTH Rev 3/17 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Email: dcp.liquorcontrol@ct.gov Website: www.ct.gov/dcp/liquorcontrol PUBLIC HEALTH CERTIFICATE I CERTIFY THAT: NAME OF PERMITTEE NAME OF BACKER TRADE NAME OF ESTABLISHMENT STREET ADDRESS 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