Scott County Health Department
Visit food.iowa.gov
# of Machines
License Fee
1
x$50.00 =
$50.00
First machine@ $50.00
x$10.00 =
Each additional @$10.00 each
Total Fee =
Mail completed application and
submit payment to:
Scott County Health Department
600 W 4th Street
Daven
port, IA 52801
Telephone: (563) 326-8618
VENDING MACHINE LICENSE APPLICATION
Date of Application:
Anticipated Opening Date _________________
Has ownership changed since
last license was issued? [ ] Yes [ ] No
If yes:
Give previous owner name ,
Business name
license number:
, and
(If known)
Establishment Information (if any information has changed, update information on renewal application
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 E-mail 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:
Attn:
Telephone Number: ( )
Street or Route: Suite# City: State: Zip code:
Commissary or Warehouse Information (location where food prepared, packaged, or stored)
Establishment Name:
License Number:
Address:
Owner:
City: State: Zip:
Phone: ( ) Cell phone: ( ) Email:
License Fee Table (please complete)
License Fee:
$50.00 for the first vending
machine and $10 for each
additional machine
DO
NOT COMPLETE INFORMATION BELOW – FOR OFFICE USE ONLY
Check #
Check Name
*Complete reverse side of application
1/1/2019
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Scott County Health Department
Telephone:
(563) 326-8618
Visit food.iowa.gov
Vending Machine Operator's License
Iowa law exempts vending machines that dispense only prepackaged non-hazardous foods from
obtaining a license. Vending machines that require a license are those dispensing the following
items:
"Non-prepackaged foods" which include post and pre-mix machines dispensing such
items as coffee, soft drinks, soups, and similar items in cups; and
• “Potentially hazardous foods" which are food products that must be stored at 41°F or
below, or 135°F or above
The operator shall maintain within the jurisdiction of the regulatory authority, a list of all
vending machines and machine locations operated by the licensee, and shall make the list
available to the regulatory authority upon request.
List the Number of Licensed Vending Machines by Location in each city, in the State of Iowa
Name of Location
Address of Location
City
Number of
Machines
Applicants Name (Print): ____________________________Applicants Signature: ________________________
1/1/2019
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