Fillable Application For Peddlers, Transient Merchants & Professional Fundraisers (City of Maple Grove)

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Application For Peddlers, Transient Merchants & Professional Fundraisers (City of Maple Grove)

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The Application For Peddlers, Transient Merchants & Professional Fundraisers (City of Maple Grove) form is 6 pages long and contains:

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  • 13 check-boxes
  • 81 other fields

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BROWSE CITY OF MAPLE GROVE (MN) FORMS

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G:/Records Unit/ Solicitor folder/ license information/peddler application REV 06/2020
Page 1
The license I am applying for:
Application for Peddlers, Transient Merchants & Professional
Fundraisers
City of Maple Grove
Police Department – Records
12800 Arbor Lakes Pkwy N
Maple Grove, MN 55369
Phone: (763) 494-6100
•
Application must be complete and legible. (Indicate not applicable (N/A) on application if appropriate.)
•
Allow a minimum of five working days for the application to be processed.
•
No peddling or soliciting until license has been issued. Peddling or soliciting prior to issuance of a license is a
violation of the City Ordinance and is cause for denial and/or an arrest.
•
Licenses expire on December 31
st
of the current year, regardless of the date issued (or earlier if so designated)
•
The total fee for a Peddlers license is $175. (Due in 2 separate payments)
•
The fee is not pro-rated and is non-refundable.
•
Failure to provide true and complete information shall constitute a violation of the ordinance in question, and in
addition to the penalties prescribed for violation of the ordinance in question, the license of any applicant may be
revoked by reason of material falsification or omission of information for said application.
A $25.00 non-refundable background fee. (If the application is approved, a fee of $150.00 will be due when you pick up your
license. Payments are accepted in the form of CASH OR CHECK ONLY)
Completed application (if something does not apply to you, please put N/A). Provide proof of
any State or County license (when applicable).
Supply 2 color photos (head & shoulders) taken within 60 days of application. Must be pre-cut to 2”x2”.
Passport style photos work great.
Supply a government issued legitimate ID to be photo copied at the time the application is turned in.
(State issued DL with photograph, Passport, Alien ID, Non-qualification card with photo or Armed Forces (active duty or reserve)
identification.)
Peddler: A person that is attempting to sell either a product or personal service. This may include setting up future contracts for
service or a person that carries the actual merchandise offered for sale, not just samples of such products, both product delivery and
payment may occur during the initial interaction or for future service.
Transient merchant: A person who temporarily sets up business out of a vehicle, trailer, boxcar, tent, other portable shelter, or
empty store front for the purpose of exposing or displaying for sale, selling or attempting to sell, and delivering, goods, wares,
products, merchandise or other personal property and who does not remain or intend to remain in any one location for more than
14 consecutive days.
Professional fundraiser: A person that is paid for canvassing activities, they are compensated for working on behalf of an
otherwise exempt group or person.
-Office Use Only-
Date application Received: Person accepting application:
Paid $25.00 fee for background check
Information:
Requirements:
Applications will not be accepted without all of the following:
G:/Records Unit/ Solicitor folder/ license information/peddler application REV 06/2020
Page 2
Application for Peddlers, Transient Merchants & Professional Fundraiser
This application form requests information, which may be classified as private or confidential under the Minnesota
Data Practices Act. This information is required by State law or City ordinance. The information will be used to
determine your eligibility for issuance of a license. Failure to provide the information will result in a denial of the
permit.
Full Legal Name:
Last First Middle (full middle name)
Other names you have used: (nickname, maiden name, etc.) _
Male
Height
Weight
Hair Color
Female
Eye color _ Race
Date of Birth
Driver’s License Number: State issued:
Permanent Home Address: (The applicant’s address, not the company address.)
Address: _ City/ State: _ Zip:
Home Phone: ( ) _ _ Other Phone: ( )
Local Address: (where you will reside while conducting business in our City)
SAA: Check here if you will be staying at the same address as above while doing business in Maple Grove.
Address: _ City/ State: _ Zip:
Local Phone Number: ( ) _ Other Phone Number: ( )
Vehicle #1: Make/Model: Year: _Color: _
License Plate Number: State of Issue:
Vehicle #2: Make/Model: Year: _ Color:
License Plate Number: State of Issue: _
Applicant’s Information:
Vehicle Information: (Please list ALL vehicles that will be used while conducting business in our city.)
G:/Records Unit/ Solicitor folder/ license information/peddler application REV 06/2020
Page 3
Business name:
Any other names the business is affiliated, owned, managed or operated by:
Address: City/State _ Zip
Phone Number: ( ) _
State Sales Tax Number, Federal Tax ID number or Social Security Number: _
Supervisor or Manager’s Name: _
Product or merchandise information:
A brief description of the nature of the business and the products to be sold:
Where is the local point of distribution and the address?
Will you have the merchandise in your possession when you are going door to door? YES NO
Application information:
Dates you are applying for the permit: Hours of the day: to
Please note: No soliciting between the hours of 7:00 p.m. and 9:00 a.m. per city ordinance.
List the three most recent locations where the applicant has conducted business as a peddler or solicitor:
1.
2.
3.
Have you been convicted within the last 5 years of any felony, gross misdemeanor, misdemeanor or petty misdemeanor
for a violation of any state or federal statute or any local ordinance, other than a petty misdemeanor traffic violation?
YES NO
Explain below the offense you were charged with, the location (City, County, and State), what you were convicted of, the
sentencing you received (fine, probation, parole, etc.) and your current status in regards to parole, probation, etc.
I agree to operate such business in accordance with the laws of Minnesota and the ordinances of the city of Maple
Grove. these statements are true, correct and are made with the knowledge that this information may be made public.
False disclosures are subject to perjury proceedings and forfeiture of the license application.
Applicant’s Signature: Date:
Business Information:
G:/Records Unit/ Solicitor folder/ license information/peddler application REV 06/2020
Page 4
Certificate of Compliance
Minnesota Workers’ Compensation Law
Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or
permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with
the workers’ compensation insurance coverage requirements of MSS Chapter 176. The information required is: the name of the
insurance company, the policy number, and dates of coverage, or the permit to self-insure. This information will be collected by the City
and retained in the files.
This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not
provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000
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.
YOUR LICENSE WILL NOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION.
You must complete number 1, 2 or 3 below.
Business Name (Individual name only if no company name used): _
Address of Business:
(Street) (City) (State) (Zip)
Insurance Company Name (NOT the Agency or Agent):
Workers’ Compensation Insurance Policy Number: _
Effective Date: Expiration Date:
I am self-insured (Include permit to self-insure)
I am not required to have workers’ compensation liability coverage because:
I have no employees
I have employees but they are not covered by the workers’ compensation law. (These include: spouse, parents, children
and certain farm employees, see MN Stat. 176.041 for a full list of excluded employees.)
ALL APPLICANTS COMPLETE THE FOLLOWING SECTION
I certify that the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify that I am
authorized to sign on behalf of the business.
Applicant’s signature Date
Number 1 – Complete this portion if you are insured:
Number 2 – Complete this portion if self-insured:
Number 3 – Complete this portion if exempt:
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signature
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G:/Records Unit/ Solicitor folder/ license information/peddler application (02/13/2017)
Page 5
Department of Public Safety Background
Investigation Consent Release
As a license applicant, I hereby give my consent for a personal background investigation, to include a criminal history
check, to be used in the determination of whether my application is to be approved. The results of such investigation
shall be made public pursuant to appropriate the Police Chief or designee’s approval or denial of the permit application.
I understand that I am under no legal obligation to consent to such investigation, but that my refusal to so consent may
be the basis for denying my application.
Type of license or permit you are applying for:
Application information:
Full legal name:
(Last) (First) (Middle)
Other names you have used: (including nickname, maiden name, etc.)
Date of Birth: Place of Birth:
Have you ever been convicted of a crime relating to this type of license or permit? YES NO
If yes, state jurisdiction, type of violation and disposition:
These statements are true, correct and are made with the knowledge that this information may be made public.
False disclosures are subject to perjury proceedings and forfeiture of the permit application.
Applicant’s Signature: Date:
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signature
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G:/Records Unit/ Solicitor folder/ license information/peddler application REV 06/2020
Page 6
Notification for License Involving Private or
Confidential Information
(Includes Tennessean Warning)
In connection with your request for a license, the City has asked that you provide information about
yourself, which is classified as private, confidential, nonpublic, or protected nonpublic under the Minnesota
Government Data Practices Act. This means that this data is not ordinarily available to the general public.
Accordingly, the City is required to inform you of the following:
1. The purpose and intended use of the information requested is to determine if you are eligible for a license
from the City of Maple Grove.
2. You are not legally obligated to supply the requested information.
3. The known consequences of supplying the requested information are that the information of further
investigation could disclose information, which could cause your application to be denied.
4. The known consequences of refusing to supply the requested information are that your request for a license
cannot be processed.
5. A criminal charge, arrest, or conviction will not necessarily bar you from obtaining a license or permit within
the City, unless the conviction is related to the matter for which the license is sought, according to Minnesota
Statute 364.03. However, failure to reveal the requested criminal information will be considered falsification
of the application and may be used as grounds for the denial of the application.
6. Other governmental agencies necessary to process your application are authorized by law to receive the
information provided.
7. The City is required by law to furnish some of this information to the Department of Labor and Industry and
the Minnesota Commissioner of Revenue.
8. During the application process, your name and address may be released to the public. If the license is
granted, all the data supplied will be available for inspection by the public.
The undersigned, by signing this notice, acknowledges that he/she has read and understood the contents
of this notice and has received a copy of this notice.
Applicant’s Signature Date
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Application For Peddlers, Transient Merchants & Professional Fundraisers (City of Maple Grove)

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Completed 14 July 2020

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