Establishment License Number: Click here to see list of Polk County Food Establishments

Date of Inspection: (format YYYY-MM-DD)

Fee Paid for Current Year? Yes No Exempt

Purpose of Inspection: Pre-Opening Follow-Up Routine Complaint Other

Person In Charge:

Inspector Name:

Proposed Follow Up Date: (text format)

Number of Critical Violations:

Number of Non-Critical Violations:

Notes: