Fillable Food Establishment License Application (including Mobile Units) (Scott County Iowa)

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Food Establishment License Application (including Mobile Units) (Scott County Iowa)

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Food Establishment License Application (including Mobile Units)
This is an application for obtaining a food establishment license from the (Iowa Department of Inspections and Appeals).
Iowa law prohibits a food establishment or food processing plant from opening or operating until a license has first been
obtained from the appropriate regulatory authority. Completed applications and documents must be submitted at least
30 days prior to the anticipated opening date.
The application must be fully completed and returned with all necessary documents and fees to the Scott County Health
Department. INCOMPLETE APPLICATIONS WILL BE RETURNED WITHOUT REVIEW.
Once applications and other required documents and fees are received and processed, the Department will review the
documents and provide the applicant with the assigned inspector’s contact information by letter once the application is
processed. The applicant is responsible for contacting the inspector to schedule a pre-operational inspection. Plan
submission is required for new construction and remodels; the Department will review the plans
and communicate the results of the plan review to the applicant. Plan reviews generally take 3 to 4 weeks. It would be
beneficial to submit the application prior to beginning construction, remodeling, or alteration of a facility. There is no
fee for plan review. Please note, failure to provide all required information could delay plan approval. If you are
remodeling a licensed facility already owned by you submit plans only with your license number and notify your
inspector.
*Remodel facilities with no change in ownership or location need only submit a floor plan and the list of equipment for the specific
area(s) of the food establishment that are affected by the remodel submitted to the address below.
MAILING A
DDRESS:
Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Phone Number: (563) 326-8618
Applicatio
n Checklist: Your application must include all of the following information:
☐ A fully completed Food Establishment License Application
☐ A copy of your intended menu
☐ Facility floor plan and equipment schedule (new construction or remodel)
☐ Water test (if using well water)
☐ Appropriate fee (check, money order, or cash)
☐ Copy of your or your staff member(s) current Certified Food Protection Manager Certificate(s) (if available, due
within 6 months of opening)
☐ Procedures and plans where specified in the Iowa Food Code
o HACCP plans (if applicable ) see Iowa Food Code section 8-201.13
o Procedures for clean-up of bodily fluids (all establishments) see Iowa Food Code Section 2-501.11
o Employee health reporting policy (all establishments)see 2-103.11
1/1/2019
Page 1 of 10
Date of Application: ______________
Anticipated Date of Opening or Ownership Change: ______________
PHYSICAL LOCATION INFORMATION
NAME
OF
FOOD
ESTABLISHMENT
:
ADDRESS OF FOOD ESTABLISHMENT:
Addr
ess and Suite # City State Zip Code
Coun
ty
(
)
Email address – (we do not share this). Cell or Alternate Phone Number
(
)______________________________ ( )____________________________________
Business Phone Number Fax Number
MAILING ADDRESS (If Other Than Above): All licensing, renewals and regulatory correspondence will be sent to this address:
Na
me Address and Suite # City/State Zip Code
1/1/2019
Page 2 of 10
License Type: (please select one of the following)
☐ Food Service Establishment (“Food service sales” are taxable food or beverage sales or
food or beverages sold for on premises consumption including alcoholic beverages, this
may include up to $20,000 in retail sales)
☐ Retail Food Establishment (“Retail sales” are non-taxable food or food products and
beverages to consumer customers intended for preparation or consumption off the
premises.)
☐ Both Food Service and Retail Food (needed if establishment has “food service sales”
and more than $20,000 per year in “retail sales”).
☐ Mobile Food Unit – also select Food Service 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.
All applicants must select one of the following:
☐ New construction of a food establishment – plan review & Equipment
Schedule required.
☐ A New food business in an physical structure not previously a food related
business. Plan review & Equipment Schedule required.
☐ Moving an existing food business to a new location.
Current Location Address:______________________________________________
Plan review & Equipment Schedule are required only if remodeling the new location.
Current License # ___________.
☐ A currently operating food business that will have new ownership with same
menu type and food service style and the facility has been actively licensed and
has been operational within the last 3 months.
Name of previous owner ______________________________________________.
☐ Opening a food business that has been non-operational for more than 3
months. List name of previous owner (if known)___________________________.
☐ Opening a new food business in a food facility that has been operational
within the last 3 months AND there will be a significant menu or food service style
change. For example – change from a fast food style restaurant to a full service
facility. List name of previous owner ____________________________________.
☐ Other, Describe___________________________________________________.
(If you are sharing a kitchen with another licensed business please note
here.
1/1/2019
Page 3 of 10
ESTABLISMENT SERVICE INFORMATION
TYPE OF SERVICE (Check all that apply)
Reta
il Service (perishable non-taxable food and ingredients sold for off premises consumption)
□ Retail Grocery Store
□ Retail Meat Department
□ Retail Seafood Department
□ Retail Produce Department
□ Retail Deli Department
□ Retail Bakery Department
□ Retail Salvage Food
□ Retail Convenience Store
□ Retail Candy Store
□ Variety Store
□ Other Retail Store
Specify________________
Food Service (taxable food sales of prepared food or beverages for consumption on the premises)
□ Dine-in Food Service
□ Take-out Food Service
□ Buffet Service
□ Salad Bar Service
□ Alcoholic Beverage Service (no food preparation)
□ Alcoholic Beverage Service (with food preparation)
□ Catering
□ Commissary (service or preparation location for
company owned outlets including vending machines
and mobile food units)
□ Concession Stand
□ Food Service Deli
□ Convenience Store Food Service
□ Continental Breakfast
□ Other Food Service Specify_____________________
Mobile Food Unit
□ Ice Cream (pre-packaged)
□ BBQ Unit
□ Push Cart
□ Concessions Truck/Trailer
□ Taco Truck
□ Frozen Food (pre-packaged)
□ Other Mobile
Specify__________________
Food Service in an Institutional setting
□ Assisted Living (production and/or service site)
□ Assisted Living (service site only)
□ Elementary School (including K-5) (Production and/or
service site)
□ Elementary School (including K-5) (service site only)
□ School (not including K-5) (production and/or service
site)
□ School (not including K-5) (service site only)
□ Elderly Nutrition Program/Senior Center (production
and/or service site)
□ Elderly Nutrition Program/Senior Center (service site
only)
□ Hospitals (non-patient food service)
□ Other Institutional Food Service Specify
___________________________________
1/1/2019
Page 4 of 10
MENU INF
ORMATION
Full S
ervice Menu (numerous items) ** attach menu Limited Menu (a few items) ** attach menu
Do you
plan on serving any animal food undercooked, raw, or cooked to order? YES NO
List: If yes, is a consumer advisory on your menu? YES NO
Do you have or have you applied for an alcoholic beverage license? ☐ YES ☐ NO ☐ N/A
PROJECTED CAPACITY
Number of seats = (Include inside and outside seating as described in the instructions. Mark ‘0’ if no seating provided)
Patrons served daily (projected)
=
EMPLOYEE INFORMATION
Anticipated # of employees/volunteers, including owner =
Do you have one or more Certified Food Protection Manager(s) on Staff who has supervisory responsibility?
☐ YES ☐
NO ☐ Exempt (only prepackaged food and beverages)
If YES, Please attach a copy of your National Certificate(s)
If NO, Do you have a Person-In-Charge enrolled in Food Safety Training? ☐ YES ☐ NO
If YES, Name, Date, and Location of Course
Do you have procedures and plans where specified in the Iowa Food Code (for example, HACCP plan if required, Employee
Health Reporting Policy, Standard Operating Procedures, Bodily Fluid Clean-up Procedures): ☐ Yes ☐ No ☐ N/A
If yes,
attach copies
If no, please have any required plans and procedures available at the pre-
opening inspection
FACILITY FLOOR PLAN & EQUIPMENT SCHEDULE REQUIREMENTS
ALL “NEW FACILITIES” AS DESCRIBED IN THE FACILITY TYPE SECTION MUST ATTACH FACILITY PLANS AND SIGN BELOW.
All facilities must submit ONE copy of a facility floor plan/layout, EXCEPT for CHANGE OF OWNERSHIP FOR AN EXISTING FACILITY
WHERE NO
CONSTRUCTION, REMODELING,
OR CHANGES ARE GOING TO OCCUR. This plan must include;
• the basic lay out of the facility,
• the location of all food service equipment,
• a listing of the equipment (including manufacturer’s names and model numbers),
• water and sewer connection locations,
• restroom locations and fixtures,
• lighting schedules,
• surface or finish coat materials of floors, walls and ceilings, and
• A site plan showing exterior building structures (including storage areas, trash receptacles, outside refrigeration units,
etc.…).
Plans may be hand drawn, to approximate scale, and must be neat and legible. Plans will not be returned to you.
*The appropriate floor plan AND equipment list are attached to this application.
Applicant Signature
1/1/2019
Page 5 of 10
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WATER, SEWER, WASTE INFORMATION
W
ATER: The facility is using: (Check which one applies)
A public or municipal water supply.
A non-public / non-municipal / private water supply (example: well water). A current water test must be provided.
Mobile Unit: Operators must always use water from a tested and approved source. Water source documentation must
be maintained on the mobile food unit.
SEWER: The facility is using: (Check which one applies)
A municipal/public sewage disposal system.
A non-public sewage disposal system
For Mobile Units: Appropriate sewage/waste holding tanks that will be disposed of at approved sanitary sewage
disposal sites.
R
EFUSE (trash collection): (Check all that apply & complete fully)
The food facility refuse/trash collector is (company name)
List any other refuse/waste collection companies (ex: grease collection)
This facility is a mobile unit and will use various approved refuse sites for disposal of refuse and waste.
DAYS OF OPERATION & TIME (Check days which apply & complete time facility is open and accessible)
S
unday Time
Monday Time
Tuesday Time
Wednesday Time
Thursday Time
Friday Time
Saturday Time
☐ If Seasonal: Indicate months of operation:
_______________________________________________________________________________
☐ If Mobile: List events or locations at which you intend to set up/sell:
OWNERSHIP INFORMATION (Select the ownership type and complete the corresponding ownership box in the
next section)
☐ SOLE PROPRIETOR ☐ LIMITED LIABILITIY CO. (LLC) OR PARTNERSHIP (LLP)
☐ PARTNERSHIP ☐ SCHOOL (K-12)
☐ CORPORATION ☐ GOVERNMENT/MUNICIPALITY
☐ NON-PROFIT ORGANIZATION
Please complete only the section that applies to your type of ownership structure:
Sole Proprietor
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
1/1/2019
Page 6 of 10
Partnership
G
eneral Partner#1
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
General Partner#2
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
Please list additional Partners on a separate sheet of paper sheet of paper
Corporation
Corporation Name
Alternate or Cell Phone ( )
Address City: State: Zip:
Fax ( )
Phone ( )
Email
President/CEO
Official Title of Signatory
Name of Corporate Official
Signature of Corporate Official
Non-Profit Organization
Name of Non-Profit Organization
Alternate or Cell Phone ( )
Address City: State: Zip:
Fax ( )
Phone ( )
Email
Organization President
Official Title of Signatory
Name of Organization Official
Signature of Organization Official
Limited Liability Company (LLC)
Name of LLC
Email
Address City: State: Zip:
Name of President
Phone ( )
Official Title of Signatory
Alternate or Cell Phone ( )
Signature of Official
Fax ( )
1/1/2019
Page 7 of 10
Limited Liability Partnership (LLP)
Member #1
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
Member #2
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
Please list Additional Partners on a separate sheet of paper.
Government/Municipality
Name of Agency
Email
Address City: State: Zip:
Agency Official’s Name
Phone ( )
Agency Official’s Title
Alternate or Cell Phone ( )
Agency Official’s Signature
Fax ( )
School (K-12)
Name of School District
Fax ( )
Address City: State: Zip:
Name of Superintendent
Phone ( )
Name of Signatory
Alternate or Cell Phone ( )
Title of Signatory
Email
Signature of Official
On-Site Contact (attach additional contacts if needed)
NAME
___________________________________________
TITLE
_________________________________________________
B
USINESS ADDRESS:_______________________________ CITY__________________ STATE_________________ ZIP_____________
PHONE ( ) ________________ CELL PHONE ( ) ____________ E-MAIL ADDRESS _____________________________
Emergency Contact
NAME
____________________________________________
TITLE
_________________________________________________
B
USINESS ADDRESS:_______________________________ CITY__________________ STATE_________________ ZIP_____________
PHONE ( ) ________________ CELL PHONE ( ) ____________ E-MAIL ADDRESS _____________________________
1/1/2019
Page 8 of 10
PLEASE CONTINUE TO THE LAST PAGE IF YOU ARE NOT APPLYING FOR A MOBILE LICENSE
PLEASE COMPLETE THE SECTION BELOW ONLY IF YOU ARE APPLYING FOR A MOBILE FOOD UNIT LICENSE:
Mobile Food Unit Applicants: Please verify that all information is accurate and sign where required, you may copy this page and
include it with this application form for each unit owned provided the Home Base address is the same for all units.
Unit Identification: REQUIRED Complete all sections. Mark N/A if not applicable.
V
IN Number or Serial Number___________________________
License Plate No. and State _____________________________
Unit and/or Truck Number______________________________
M
ake__________________ Model___________________
Year___________ Size___________ Color______________
Home Base of Operation
List the address of the Home Base for the Mobile Food Unit (This is where the unit will be serviced or stored when not in
operation)
S
treet Number and Name City State Zip Code
C
ounty
I
f the Home Base is a licensed food establishment, provide the license number. If not, state N/A: ___________________
A
ll food storage and preparation must be done in the mobile unit or in your licensed food establishment/commissary.
Additional Requirements
I
f the unit is normally set up in the same location each day and does not have a plumbed restroom, an agreement with a neighboring
business for use of a restroom must be obtained. (Please attach restroom agreement and enter address here)
__________________________________________________________________________________________________________
I understand mobile food units may only operate up to three days in one location unless they return to their home base of operation
each day. Signature __________________________________________
I understand all food service operations must be conducted within the mobile food unit with the exception of grills and smokers.
Signature ____________________________________________
Additional Permits
C
heck with City and County government agencies to if additional permits are required
Verification
A
copy of the unit license and most recent inspection report must be posted on the unit in a conspicuous location.
I have read, and understand, the requirements in the Iowa Mobile Food Unit Operation Guide.
I
verify all of the information contained in the application is accurate.
S
ignature ________________________________________________________
Printed name of Signatory __________________________________________
1/1/2019
Page 9 of 10
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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
coffee 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: Scott County Health Department
600 W 4
th
Street
Davenport, IA 52801
Phone Number: (563) 326-8618
Make Checks payable to Scott County Treasurer
Check # ____________________
Check Date __________________
Amount Received ____________
Check Name _________________
Penalty amount _____________
Amount Due ________________
FOR OFFICE USE ONLY
1/1/2019
Page 10 of 10
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Food Establishment License Application (including Mobile Units) (Scott County Iowa)

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Completed 14 February 2021

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