Scott County Food Processing Plant License Application

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Scott County Food Processing Plant License Application Powered By Docstoc
					SCOTT COUNTY HEALTH DEPARTMENT
Administrative Center
600 West 4th Street
Davenport, Iowa 52801-1030
Office: (563) 326-8618 Fax: (563) 326-8774
www.scottcountyiowa.com/health

                                       APPLICATION FOR FOOD PROCESSING PLANT LICENSE
A Food Processing Plant is a commercial operation that manufactures, packages, labels, or stores food for human
consumption and does not provide food directly to a consumer. A Food Processing Plant does not include premises
covered by a class ’A’ beer permit. A license is not transferable or refundable and any change in location or
ownership requires a new license.

Opening Date: _______________________________                                                        - New Establishment
Date Application Submitted: ___________________                                                      - Change of Owner


Establishment Name: _________________________________________________ Phone: ________________________

Person in Charge: ___________________________________________________________________________________

Physical Address:____________________________________________________________________________________
                       Street                           City                      State        Zip

Mailing Address: ____________________________________________________________________________________
                      Street                           City                       State        Zip


Name of Owner/Corporation: __________________________________________________________________________

Address of Owner: ___________________________________________________________________________________
                      Street                           City                      State         Zip

Scope of Business for Food Processors (Please state what type of food products are being stored at this location):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Make Check Payable To: Scott County Treasurer

The license fee is based on the total gross sales or value of product stored at this physical address on an annual basis.

License Fee: $_______________


                     Please check appropriate box:

                                           ο $ 67.50 Annual gross sales of less than $50,000
                                           ο $135.00 Annual gross sales of $50,000 to $249,000
                                           ο $202.50 Annual gross sales of $250,000 to $499,000
                                           ο $337.50 Annual gross sales of $500,000 or more




(Signature of Applicant)
The Scott County Health Department reserves the right to approve, accept, disapprove or reject this instrument for a reasonable period of time and attaches no legal
right or obligation to the immediate processing of remittance.

7/07lrg

				
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