Telephone: (563) 326-8618
HOME BAKERY LICENSE APPLICATION
Date of Application:
Anticipated Opening Date:
Mail completed application to:
Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Previous owner name ,
business name , and
license number (if known).
License Fee: $50.00
Establishment Information
Note: A new application is required for change in the business address or ownership.
Name of Business:
Ownership Type:
Owner’s Name:
Business Phone Number:
Alternative or Cell Phone:
Business Email Address:
Physical Business Address:
Suite #:
County:
City
State:
Zip Code:
Person-in-Charge (onsite):
Title of Person-in-Charge:
Person-in-Charge Phone:
Person-in-Charge Email:
Mailing address for all correspondence (if different than above).
Attention:
Telephone Number:
Street or Route:
Suite:
City:
State:
Zip Code:
A Home Bakery Establishment is a licensed bakery located in a residence. A Home Bakery Establishment may prepare
refrigerated or unrefrigerated baked goods for sale directly to household consumers for off-premises consumption or to other
retail outlets. Baked goods that do not require refrigeration may be sold from the residence or at a farmer’s market without a Home
Bakery Establishment License. Baked goods are defined as: breads, cakes, donuts, pastries, buns, rolls, cookies, biscuits and pies
(except meat pies).
Sales Type
(Select all that apply)
Farmer’s Market
Internet
Mail Order
Restaurants
Wholesale
Other specify
Product Information
Breads
Cakes
Pastries
Buns
Rolls
(Select all that apply)
Cookies
Biscuits
Pies
Other specify
License Fee: $50.00
DO NOT COMPLETE INFORMATION BELOW FOR OFFICE USE ONLY
Check #:
Check Date:
Amount Received
Check Name:
Penalty Amount:
Amount Due:
Applicant’s Name (Print):
Applicant’s Signature:
1/1/2019
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