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Scott County Home Food Establishment Application

VIEWS: 5 PAGES: 1

									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 HOME FOOD ESTABLISHMENT LICENSE

A home food establishment is a business on the premise of a residence where potentially hazardous bakery products
are prepared for consumption off-the-premise. Potentially hazardous bakery products are those that require refrigeration,
such as: soft pies and items with custard or cream filling. Annual gross sales of a home food establishment must be
under $20,000. Please call the inspector at least 24 hours prior to the opening date to set up a time for the
inspection.

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: _____________________________________________                                         - Individual         - Partnership          - Corporation

Address of Owner: ___________________________________________________________________________________
                      Street                           City                      State         Zip


Make Check Payable To: Scott County Treasurer

License Fee:         $33.75




_______________________________________________________________________________________________                             ________________________________
                                            Signature of Applicant                                                                            Date
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




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