Scott County Health Department
# of Machines
License Fee
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)
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
*Complete reverse side of application
