LICENSE FEES- All applicants must select the appropriate license type and fee. Refer to page 3-4 of this application to ensure
that license types match.
*Pay from the appropriate Fee Schedule based on the following: A new establishment, as described on page 3 of this
application, must pay the maximum fee indicated in the fee box that is applicable to the license(s) applied for. If this food
establishment is a Change in Ownership as described on page 3 the fee level is set based on the gross annual sales of the
previous owner, if the previous owner has operated the business within the last 3 months. Proof of the last 12 months of
the previous owner’s sales must accompany this application otherwise; the maximum fee must be paid.
………..……..………………………………………………………………………………………………………………………………………………………………………….
☐ Food Service Establishment - Examples include restaurants, bars or taverns, take-out food, catering commissary,
concession stands, etc. License fees are based on annual gross sales of “Food service sales” which are taxable food or
beverage sales and/or food or beverages sold for individual portion service intended for consumption on the premises,
including alcoholic beverages, and may include up to $20,000 in retail sales. Select the appropriate fee:
☐ $0.00- Schools
☐ $150- Annual gross sales of $1 to $100,000
☐ $300- Annual gross sales of $100,001 to $500,000
☐ *$400- Annual gross sales of $500,001 +
OR:
☐ Retail Food Establishment - Examples include grocery and convenience stores without prepared foods, bakeries
without seating, etc. License fees are based on annual gross sales of non-taxable food or food products and beverages to
consumer customers intended for preparation or consumption off the premises. Select the appropriate fee:
☐ $150- Annual gross sales of $1 to $250,000
☐ $300- Annual gross sales of $250,001 to $750,000
☐ *$400- Annual gross sales of $750,001 +
OR:
☐ Both Food Service and Retail Food (needed if establishment has “food service sales” and more than $20,000 per
year in “retail sales”). Examples include- Grocery and Convenience stores that prepare food, Bakery with a sit down
c
offee shop, etc.
To determine the amount owed, select your dominant form of business above (Food Service Establishment or
Retail Food Establishment) and select the corresponding fee based on sales (if proof of sales is not provided
this fee will be $400). Then add $150 for the secondary license.
☐ $150 for the secondary form of business (ensure Food Service or Retail Food Establishment Fee box is checked
above)
OR:
☐ $250 Mobile Food Unit – Examples include Food trucks and Push Carts. Must also select Food Service
Establishment above if you have a commissary at the same physical address.
If you have a commissary at a different location an additional application is required for that location.
Submit payment to: Johnson County Public Health
855 S Dubuque St Suite 217
Iowa City IA 52240
Phone Number: (319)356-6040
Make Checks payable to Johnson County Public Health
Check # ____________________
Check Date __________________
Amount Received ____________
Check Name _________________
Penalty amount _____________
Amount Due ________________