Fillable 2019 05 03 License Application Final Fillable (City of Duluth)

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2019 05 03 License Application Final Fillable (City of Duluth)

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CITY OF DULUTH
CITY CLERK’S OFFICE
330 City Hall
411 West First Street
Duluth, Minnesota 55802
www.duluthmn.gov
Phone: (218) 730-5500
Fax: (218) 730-5293
SHARED ACTIVE MOBILITY SYSTEMS
LICENSE APPLICATION
SHARED ACTIVE MOBILITY SYSTEM (“SAMS”)
LICENSE FEE:
$500.00
License Period: January 1st – December 31st
PER DEVICE FEE:
NO. OF DEVICES:
$50.00
x_____________
TOTAL DEVICE FEES:
TOTAL DUE:
LICENSEE BUSINESS NAME, ADDRESS, PHONE AND EMAIL:
(Individual, Partnership, Corporation, LLC)
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
EMAIL: ____________________________________
BUSINESS PHONE: _
__________________________
LOCAL AGENT NAME & ADDRESS:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
LOCAL AGENT PHONE AND EMAIL:
(Available 24/7)
EMAIL: ____________________________________
BUSINESS PHONE: ___________________________
LICENSEE HEREBY SWEARS AND ATTESTS THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT TO THE BEST OF ITS KNOWLEDGE AND THAT
LICENSEE SHALL COMPLY WITH ALL PROVISIONS GOVERNING ITS OPERATION SET FORTH IN ITS OPERATING AGREEMENT AND CHAPTER 9A OF THE DULUTH CITY
CODE, ALONG WITH ALL OTHER APPLICABLE PROVISIONS OF LOCAL, STATE OR FEDERAL LAW, AS MAY BE AMENDED.
BY: ___________________________________________________
LICENSEE OR ITS DULY AUTHORIZED AGENT OR REPRESENTATIVE
STATE OF _____________ ]
] ss:
COUNTY OF ___________
On this ____ day of ___________ 20___, before me, a Notary Public within and for said County and State, personally appeared ________________, to me
known to be the person named in and who executed the foregoing instrument, and acknowledged that they executed said instrument as their free act and deed, for
the uses and purposes therein expressed.
_____________________________________
NOTARY PUBLIC
My Commission Expires _________________
For Office Use Only
Date:
License No.
GOVERNMENT DATA PRACTICES ACT - CLASSIFICATION WARNING: The data you supply on this form will be used to process the license you
are applying for. You are not legally required to provide this data, but we will not be able to
process the license without it. Some of the
data will be classified as public data if and when the license is granted. Private finan
cial information including a tax identification number
and social security number are classified as private data and will be available to governmental personnel and other governmental
agencies whose access is necessary to perform their official duties.
SHARED ACTIVE MOBILITY SYSTEMS LICENSE
APPLICATION CHECKLIST
ALL OF THE FOLLOWING ITEMS MUST BE SUBMITTED FOR CONSIDERATION WITH YOUR APPLICATION:
LICENSE PAYMENT (ANNUAL LICENSE FEE + PER DEVICE FEE)
EXECUTED OPERATING AGREEMENT WITH THE CITY OF DULUTH
MINNESOTA WORKER’S COMPENSATION COMPLIANCE/EXEMPTION CERTIFICATE
CORPORATE DOCUMENTATION (IF INCORPORATED OR PARTNERSHIP)
• Certificate of Incorporation from the Minnesota Secretary of State’s Office or proof of current
registration with the Minnesota Secretary of State establishing legal authorization to operate within the
State of Minnesota.
• Executed statement listing all entity owners including percentage of ownership held by each individual
or entity.
INSURANCE CERTIFICATE DOCUMENTING INSURANCE COVERAGES AS REQUIRED IN THE OPERATING
AGREEMENT.
FORM APPOINTING A SAMS AGENT/POWER OF ATTORNEY FOR OFFICIAL NOTICES AND SERVICE OF LEGAL
PROCESS
TAX IDENTIFICATION FORM PURSUANT TO MINN STAT. § 270C.72, SUBD. 3, AS MAY BE AMENDED
LIST OF ALL SAMS DEVICES OPERATING WITHIN THE CITY OF DULUTH, INCLUDING IDENTIFICATION NUMBERS.
SHARED ACTIVE MOBILITY SYSTEMS
SAMS AGENT FOR NOTICES/SERVICE OF PROCESS/POWER OF ATTORNEY
KNOWN ALL BY THESE PRESENT, that I _____________________________ (Name of Licensee and/or Duly Authorized
Representative or Agent), having applied for a license to operate a Shared Active Mobility System (“SAMS”) within the
City of Duluth, do hereby make, constitute and appoint:
SAMS AGENT NAME & ADDRESS:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
SAMS AGENT PHONE AND EMAIL:
(Available 24/7)
EMAIL: ____________________________________
BUSINESS PHONE: ___________________________
and his/her successor in office, my true and lawful ATTORNEY, on whom all notices, summonses and all legal processes
in any action or legal proceeding against me, arising from or on account of the operation of said SAMS within the City of
Duluth, may be served. Said ATTORNEY is hereby duly authorized and empowered, as my agent, to receive and accept
service of all notices, summonses and all legal processes in any action or legal proceeding against me aforesaid, as
provided by the laws of the State of Minnesota, and such service shall be deemed valid personal service upon me, said
_______________________________ (Name of Licensee).
This appointment is to continue in force irrevocably so long as any such SAMS is operated under the above-mentioned
permit, and so long as any liability arising from or on account of said operation of such SAMS remains outstanding.
IN WITNESS WHEREOF, I have underto set my hand at the City of Duluth, Minnesota, this _____ day of
_________________, 20___.
___________________________________________
Signature of Applicant/Licensee
STATE OF _____________ ]
] ss:
COUNTY OF ___________ ]
On this ____ day of ___________ 20___, before me, a Notary Public within and for said County and State,
personally appeared ________________, to me known to be the person named in and who executed the foregoing
instrument, and acknowledged that they executed said instrument as their free act and deed, for the uses and purposes
therein expressed.
_____________________________________
NOTARY PUBLIC
My Commission Expires __
_______________
SHARED ACTIVE MOBILITY SYSTEMS
DEVICE INVENTORY
A LIST OF ALL DEVICES OPERATING WITHIN THE CITY OF DULUTH MUST REMAIN CURRENT AND ON FILE AT ALL TIMES
IN THE CITY CLERK’S OFFICE. PLEASE SUPPLEMENT THIS FORM AS NECESSARY.
LICENSEE NAME: ____________________________________________________________________________________
DEVICE DESCRIPTION
IDENTIFICATION NO.
For Office Use Only
Date:
License No.
LIC 04 (11/16)
Certificate of Compliance
Minnesota Workers’ Compensation Law
This form must be completed by the business license applicant.
Print in ink or type
Minnesota Statutes § 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or
permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the workers'
compensation insurance coverage requirement of Minn. Stat. chapter 176. If the required information is not provided or is falsely
stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner of the Department of Labor and Industry.
A valid workers’ compensation policy must be kept in effect at all times by employers as required by law.
License or certificate number (if applicable)
Business telephone number
Alternate telephone number
Business name (Provide the legal name of the business entity. If the business is a sole proprietor or partnership, provide the owner’s
name(s), for example John Doe, or John Doe and Jane Doe.)
DBA (“doing business as” or “also known as” an assumed name), if applicable
Business address (must be physical street address, no P.O. boxes)
City
State
ZIP code
County
Email address
You must complete number 1 or 2 below.
Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes.
1. I have a workers’ compensation insurance policy.
Insurance company name (not the insurance agent)
Policy number
Effective date
Expiration date
I am self-insured for workers’ compensation. (Attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.)
2. I am not required to have workers’ compensation insurance because:
I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and messenger
courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other
industries.)
I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition
of an employee.)
I use independent contractors and I have employees who are not required to be covered by the workers’
compensation law. (Explain below.)
I only have employees who are not required to be covered by the workers’ compensation law. (Explain below.) (See
Minn. Stat. § 176.041 for a list of excluded employees.)
Explain why your employees are not required to be covered
I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am
authorized to sign on behalf of the business.
Print name
Applicant signature (required)
Title
Date
If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or
1-800-342-5354.
Reset
MN STATUTE 270C.72 TAX IDENTIFICATION FORM
PURSUANT TO Minnesota Statute 270C.72, Tax Clearance Required: The licensing authority is required to
provide the Minnesota Commissioner of Revenue the business tax identification number and social security
number of each applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of
1974, we are required to advise you of the following regarding the use of this information:
1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you
owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest.
2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department
of Revenue. However, under the Federal Exchange of Information Agreement, the Department of
Revenue may supply this information to the Internal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or
renewal application.
Please supply the following information and return along with your application to the agency issuing
the license.
License applied for or renewed: _________________________________________________________________
Licensing authority: City of Duluth, St. Louis County, Minnesota
License renewal date: ______________________________________
Personal Information (if applicable)
Applicants Name: ________________________________________________________________________
Applicant’s Address: ________________________________________________________________________
Social Security Number: _____________________________
Business Information (if applicable)
Business Name: ________________________________________________________________________
Business Address: ________________________________________________________________________
MN Tax Identification Number: _____________________________________
Federal Tax Identification Number: __________________________________
Signature__________________________________________________________Date______________________
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2019 05 03 License Application Final Fillable (City of Duluth)

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Completed 15 July 2020

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