Fillable Unattended Food Establishment License Application (Scott County Iowa)

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Unattended Food Establishment License Application (Scott County Iowa)

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Unattended Food Establishment License Application
*Note: A new application is required for change in the business address or ownership.
This is an application for obtaining Unattended 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 unattended food establishment shall be located in the interior of a building that is not accessible by the general public.
Access to the unattended food establishment shall be limited to a defined population (e.g., employees or occupants of the
building where the establishment is located).
The application must be fully completed and returned with all necessary documents and fees to the Scott County Health
Department 30 days prior to opening. 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 unattended food establishment that are affected by the remodel submitted to the address below.
MAILING ADDRESS:
Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Phone Number: (563) 326-8618
Application Checklist: Your application must include all of the following information:
☐ A fully completed Unattended Food Establishment License Application
☐ Facility floor plan and equipment schedule (new construction or remodel)
o Appropriate fee (check, money order, or cash)
1/1/2019
Page 1 of 7
Date of Application: _________
Anticipated Date of Opening or Ownership Change: ______________
PHYSICAL LOCATION INFORMATION
NAME
OF
YOUR BUSINESS
:
N
AME OF BUSINESS OR BUILDING WHERE THE UNATTENDED FOOD ESTABLISHMENT WILL BE LOCATED
__
___________________________________________________________________________________
A
DDRESS OF UNATTENDED FOOD ESTABLISHMENT:
Address and Suite # City State Zip Code
C
ounty
( )
Your Business Email address – (we do not share this). Your Cell or Alternate Phone Number
( )___________________________ ( )____________________________________
Your Business Phone Number Your Business Fax Number
Y
OUR MAILING ADDRESS (If Other Than Above): All licensing, renewals and regulatory correspondence will be sent to this address:
A
ttention to Address and Suite # City/State Zip Code
All applicants must select one of the following:
☐ New location that has NOT previously been license as an Unattended Food Establishment or
a Vending Machine location. Facility floor plan and equipment schedule are required.
☐ New location that was previously a Vending Machine location. Facility floor plan and equipment
schedule are required.
OR – Change of Ownership
☐ A location that was previously licensed as an Unattended Food Establishment that will be
under new ownership and the facility floor plan and Equipment will remain the same. List name
of previous owner/vendor _____________________________________.
☐ A location that was previously licensed as an Unattended Food Establishment that will be
under new ownership and either the facility floor plan or equipment will be different. Floor plan
and equipment schedule are required. List name of previous owner/vendor
__________________________________
1/1/2019
Page 2 of 7
Facility Information
Is this establishment located in an area of the building that has
controlled entry to the establishment that is not accessible to the
general public?
☐
Yes
☐ No
If No, please explain
If Yes, enter NA
Will the establishment provide only commercially packaged foods
properly labeled for retail sale or whole uncut fruits, vegetables or
nuts in a shell that require peeling or hulling before consumption?
☐ Yes
☐ No
If No, please explain
If Yes, enter NA
Will the establishment be equipped with refrigeration or freezer
units that have self-closing doors that allow food to be viewed
without opening the door to the refrigerated cooler or freezer?
☐
Yes
☐ No
If No, please explain
If Yes, enter NA
Will coolers and freezers be equipped with automatic self-locking
mechanism that prevents the consumer from accessing the food in
the event the equipment fails to maintain proper temperatures?
☐ Yes
☐ No
If No, please explain
If Yes, enter NA
Will the establishment provide continuous video surveillance that
provides sufficient resolution to identify situations that may
compromise food safety or food defense in areas where
consumers view, select, handle and purchase products?
☐
Yes
☐ No
If No, please explain
If Yes, enter NA
Will the permit holder service the unattended food establishment at
least weekly?
Service may include, but is not limited to the following:
• Checking food supplies and equipment for signs of
product damage, tampering, or both.
• Verifying refrigeration equipment is operating properl
y
i
ncluding the temperature display and self-locki
ng
m
echanism.
• Rotating foods to better ensure first in/first out of f
ood
items.
• Cleaning food service equipment and food display areas.
• Stocking food and disposable single-use and single-
service supplies.
• Checking inventory for recalled foods.
☐
Yes
☐ No
If No, please explain
If Yes, enter NA
Will the permit holder ensure the food is maintained at safe
temperatures during transport and display?
☐
Yes
☐ No
If No, please explain
If Yes, enter NA
Will the establishment have a signage visible at the automated
payment station?
Signage stating:
The name and mailing address of the business entity responsible
for the establishment and to whom complaints and comments
should be addressed.
• The telephone, email or web information for the
r
esponsible business entity, when applicable.
☐ Yes
☐ No
I
f No, please explain
If Yes, enter NA
1/1/2019
Page 3 of 7
Is there a written agreement between the establishment owner and
the building owner that outlines the provisions of supportive
facilities and services such as janitorial and restroom facilities, pest
control and removal of solid waste. Include what actions will be
taken by both parties to maintain the establishment in compliance
with all requirements- including responding to imminent health
hazards?
☐ Yes
☐ No
If No, please explain
If Yes, enter NA
When requested by the regulatory authority for the purposes of
conducting an inspection, will the permit holder provide an on-site
person in charge within a reasonable time frame not to exceed four
hours?
☐ Yes
☐ No
If No, please explain
If Yes, enter NA
Additional Information to submit with this application
*FACILITY FLOOR PLAN & EQUIPMENT SCHEDULE
ALL “NEW FACILITIES” AS DESCRIBED IN THE FACILITY TYPE SECTION MUST
ATTACH FACILITY PLANS AND SIGN All facilities must submit ONE copy of a facility floor plan/layout, EXCEPT for CHANGE OF
OW
NERSHIP FOR AN EXISTING FACILITY WHERE NO CONSTRUCTION, REMODELING, OR CHANGES ARE GOING TO OCCUR
.
This plan must include;
•
t
he basic lay out of the facility,
• t
he location of all food service equipment,
•
a
listing of the equipment (including manufacturer’s names and model numbers),
Plans may be hand drawn, to approximate scale, and must be neat and legible. Plans will not be returned to you. *Remodel
facilities 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.
*The appropriate floor plan AND equipment list are attached to this application.
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
Partnership
General 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
1/1/2019
Page 4 of 7
General Partner#3
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
Corporation
Corporation Name
Alternate or Cell Phone ( )
Address City: State: Zip:
Fax ( )
Phone ( )
Email
President/CEO
Signature of Corporate Official
Name of Corporate Official
Official Title of Signatory
Non-Profit Organization
Name of Non-Profit Organization
Alternate or Cell Phone ( )
Address City: State: Zip:
Fax ( )
Phone ( )
Email
Organization President
Signature of Organization Official
Name of Organization Official
Official Title of Signatory
Limited Liability Company (LLC)
Name of LLC
Email
Address City: State: Zip:
Name of President
Phone ( )
Signature of Official
Alternate or Cell Phone ( )
Official Title of Signatory
Fax ( )
Limited Liability Partnership (LLP)
Member #1
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
1/1/2019
Page 5 of 7
Member #2
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
Member #3
First Name
Alternate or Cell Phone ( )
Last Name
Email
Address: City: State: Zip:
Fax ( )
Phone ( )
Signature
Please list additional Members on a separate sheet of paper
On-Site Contact (attach additional contacts if needed)
NAME
____________________________________________
TITLE
___________________ _____________________________
BU
SINESS ADDRESS: _______________________________ CITY__________________ STATE_________________ ZIP_____________
PHONE ( ) ________________ CELL PHONE ( ) ____________ E-MAIL ADDRESS ____________________________
On-Site Contact (attach additional contacts if needed)
NAME
____________________________________________
TITLE
___________________ _____________________________
BU
SINESS ADDRESS: _______________________________ CITY__________________ STATE_________________ ZIP_____________
PHONE ( ) ________________ CELL PHONE ( ) ____________ E-MAIL ADDRESS ____________________________
Emergency Contact (required)
NAME
____________________________________________
TITLE
___________________ _____________________________
BU
SINESS ADDRESS: _______________________________ CITY__________________ STATE_________________ ZIP_____________
PHONE ( ) ________________ CELL PHONE ( ) ____________ E-MAIL ADDRESS ____________________________
Verification
A copy of the license and most recent inspection report must be posted in the
facility in a conspicuous location.
I verify all of the information contained in the application is accurate.
S
ignature ________________________________________________________
P
rinted name of Signatory __________________________________________
1/1/2019
Page 6 of 7
click to sign
signature
click to edit
LICENSE FEE*
☐ $75 for Annual gross sales of less than $100,000
☐ $150 for Annual gross sales of greater than $100,000
*All applicants must select and pay the appropriate fee. A fee of $150 must be submitted unless one of the following is
submitted showing the location's previous gross food and beverage sales history for the most recent 12 months
☐ Submitted industry accepted calculation of estimated gross food and beverage sales. This estimate must be itemized
and justified and not an estimated gross sales figure.
☐ Submitted annual gross food and beverage sales from the previous owner, if a location ownership change.
☐ Submitted annual gross food and beverage sales from vending machines, if location was previously a vending machine
location.
Submit payment to: Scott County Health Department
600 W 4th Street
Davenport, IA 52801
Phone Number: (563) 326-8618
Make Checks payable to Scott County Treasurer
FOR OFFICE USE ONLY BELOW THIS LINE
Check #
Check Date
Amount Received
Check Name
Penalty amount
Amount Due
1/1/2019
Page 7 of 7
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Unattended Food Establishment License Application (Scott County Iowa)

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Completed 14 February 2021

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