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2. Application Type

   1. New
   2. Renewal
4. Class
6. This form must be completed before the application will be submitted to the Black Hawk County Board of Supervisors.
8. Business Name
10. Address
12. City
13. State
14. Zip Code
16. We, the undersigned have inspected the above mentioned premise(s) and found that this establishment meets the minimum standards as set forth by all applicable laws and ordinances.
18. Black Hawk County Health Department Comments
20. Approved By:
21. Date
    Date
23. Fire Inspection Comments
25. Compliance

    1. Applicant Is in Compliance
    2. Applicant Is Not in Compliance
27. Approved By:
28. Date
    Date
30. Sheriff
    We have researched the applicable record of the above mentioned establishment and find no felony convictions.
32. Approved By:
33. Date
    Date
35. Status: Board Action
36. Date
    Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field