Fillable Boardingkennel Boarding Kennel License Application (City of Duluth)

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Boardingkennel Boarding Kennel License Application (City of Duluth)

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FOR OFFICE USE ONLY
DATE ________________
LICENSE # ____________
CITY OF DULUTH
CITY CLERK’S OFFICE
330 City Hall ! 411 West First Street
Duluth, Minnesota 55802-1189
Phone (218) 730-5500
Fax (218) 730-5923
LICENSE APPLICATION
Type in your information by tabbing through the boxes below. Print, sign and submit to the address above.
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 financial 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.
BOARDING KENNEL LICENSE (see choices below for fee amount) FEE ENCLOSED
3-11 animals ($83.00) =
$
OR 12 or more animals ($132.00) =
LICENSEE BUSINESS NAME & ADDRESS
__________________________________________
__________________________________________
__________________________________________
MANAGER’S NAME, ADDRESS & PHONE NO.
__________________________________________
__________________________________________
__________________________________________
__________________________________________
TRADE NAME: ____________________________
BUSINESS PHONE: _________________________
OWNER OF BUSINESS PREMISES:
___________________________________________
___________________________________________
___________________________________________
LICENSE PERIOD: JANUARY 1 TO DECEMBER 31
WORKERS COMPENSATION COMPANY
NAME: ___________________________________
POLICY NO. _______________________________
EXP. DATE _______________________________
$3,000 CORPORATE
SURETY BOND REQUIRED
I HEREBY STATE THAT ALL INFORMATION HERE IS TRUE AND CORRECT AND THAT I SHALL COMPLY
WITH ALL PROVISION 0F THE ORDINANCES OF THE CITY OF DULUTH AND LAWS OF THE STATE OF
MINNESOTA AND THEIR AMENDMENTS.
MAILING ADDRESS: _____________________________________________
Signature of Applicant
________________________________
________________________________
________________________________
LIC 04 (3/13)
Certificate of Compliance
Minnesota Workers’ Compensation Law
THIS FORM MUST BE COMPLETED BY THE BUSINESS LICENSE APPLICANT
PRINT IN INK or TYPE.
Minnesota Statutes, 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 in Minnesota until the applicant presents acceptable evidence of compliance with the
workers' compensation insurance coverage requirement of Minnesota Statutes, 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 NO (if applicable)
BUSINESS TELEPHONE NO.
FAX TELEPHONE NO.
BUSINESS NAME
(Use the person(s) name if business structure is sole proprietor or partnership (i.e., John Doe, or John Doe and Jane Doe), otherwise it is
the legal name of the business entity.)
DBA (“doing business as” or also known as an assumed name) (if applicable)
BUSINESS ADDRESS (must be physical street address, no PO boxes)
CITY STATE ZIP CODE
COUNTY
E-MAIL ADDRESS
YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE
FOLLOWING INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 – Workers’ compensation insurance policy information
NAIC Number
POLICY NO.
EFFECTIVE DATE
EXPIRATION DATE
NUMBER 2 – Reason for exemption from workers’ compensation insurance
If you have questions regarding the need to obtain workers’ compensation coverage, including exemptions, contact
651.284.5032 or 1-800-342-5354.
I have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee.)
I am self-insured for workers’ compensation (attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce).
I have employees but they are not covered by the workers’ compensation law. (See Minn. Stat. § 176.041 for a list of
excluded employees.) Explain why your employees are not covered:
______________________________________________________________________________________________
Other: _________________________________________________________________________________________
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.
PRINT NAME
APPLICANT SIGNATURE (required)
TITLE
DATE
NOTE: You must notify us if there is any change to your Workers’ Compensation Insurance Information or Employee Status Change by resubmitting this form.
This material can be made available in different forms, such as large print, Braille or on a tape.
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)
Applicant’s Name: ______________________________________________________
Applicant’s Address: ______________________________________________________
Social Security Number: ______________________________________________________
Business Information (if applicable)
Business Name: ___________________________________________________________
Business Address: ___________________________________________________________
Minnesota Tax Identification Number: ______________________________________________
Federal Tax Identification Number: ______________________________________________
If a MN Tax I.D. is not required, please explain:
Signature ____________________________________ Date ________________
BOND NO.
CORPORATE SURETY BOND FOR:
Pet Shop Grooming Shop Dog or Cat Breeding Kennel
Boarding Kennel Animal Shelter Nuisance Wildlife Removal Business
(Select appropriate one)
CITY OF DULUTH ST. LOUIS COUNTY STATE OF MINNESOTA
KNOW ALL MEN BY THESE PRESENTS:
THAT _______________________________________________________________________
(Name)
as Principal, and _____________________________________________________________________
(Name of Surety)
a corporation authorized to transact corporate surety business in the State of Minnesota, as Surety, are jointly
and severally held and firmly bound to the City of Duluth, its successors and assigns, and to other obligees
as described herein in the sum of THREE THOUSAND DOLLARS ($3,000) to be paid to the City of Duluth
or any veterinarian suffering financial loss due to the Principal’s failure to pay bills for services rendered by
such veterinarian who is assisting the animal shelter control officer in investigating animal cruelty at Principal’s
facility or is caring for any ill or injured animal removed from Principal’s facility by the animal control officer,
for the payment of which, well and truly to be made, we bind ourselves, and each of us, our and each of our
heirs, executors, administrators, successors and assigns, firmly by these presents.
THE CONDITION of the above obligation is such that WHEREAS the said Principal is about to be
granted a license pursuant to Article VIII of Chapter 6 of the Duluth City Code, 1959.
NOW, THEREFORE, if said principal shall conduct its operation in conformity with the laws of the City
of Duluth of State of Minnesota, and if the Principal shall pay when due all bills of veterinarians secured by
the City of Duluth to investigate animal cruelty complaints at Principal’s facility or to treat ill or injured animals
removed by the animal control officer from Principal’s facility, then this obligation shall be void; otherwise to
remain in full force and effect.
This bond shall be effective and run concurrently with the period of the aforesaid license from the date
said license is granted.
Signed this ____________ day of ________________________, 20____.
Signed, sealed and delivered
in the presence of:
(as to Principal)
________________________________________ __________________________________________
Principal
________________________________________
(as to Surety)
________________________________________ __________________________________________
________________________________________ __________________________________________
Countersigned by _________________________
Minnesota Resident Agent
(If required)
ACKNOWLEDGMENT OF PRINCIPAL (INDIVIDUAL)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this ____________ day of _____________________, 20___, before me personally appeared
_______________________________________________________________________ to me known to be
the person described in and who executed the foregoing bond as Principal, and acknowledged that he/she
executed the same as his/her free act and deed.
_______________________________________
Notary Public, St. Louis County, Minn.
(Notarial Seal) My Commission expires ___________________
ACKNOWLEDGMENT OF PRINCIPAL (PARTNERSHIP)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this ____________ day of _____________________, 20___, before me personally appeared
__________________________________ and ________________________________ to me known to be
the persons described in and who executed the foregoing bond as partners, and acknowledged that they
executed the same as their free act and deed and as the free act and deed of the partnership named in said
bond as Principal.
_______________________________________
Notary Public, St. Louis County, Minn.
(Notarial Seal) My Commission expires ___________________
ACKNOWLEDGMENT OF PRINCIPAL (CORPORATION)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this ____________ day of _____________________, 20___, before me personally appeared
_______________________________ and _____________________________, to me personally known,
who being by me duly sworn, did say that they are the ________________________________________
and ________________________________________ of the corporate principal above named, that the seal
affixed to the foregoing instrument is the corporate seal of said Principal, and that said instrument was
executed in behalf of said corporation by authority of its board of directors and said officers acknowledged said
instrument to be the free act and deed of said corporation.
_______________________________________
Notary Public, St. Louis County, Minn.
(Notarial Seal) My Commission expires ___________________
ACKNOWLEDGMENT OF CORPORATE SURETY
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this ____________ day of _____________________, 20___, before me personally appeared
_______________________________________________________________. who, being by me duly sworn,
deposes and says that he is the Attorney-in-Fact of the corporation which executed the foregoing bond as
Surety, and that the seal affixed to said bond is the corporate seal of said corporation and that said bond was
executed in behalf of said corporation by authority of its Board of Directors, that said corporation holds a
certificate of the Insurance Commissioner of the State of Minnesota, showing that said corporation is
authorized to contract as such surety, and said Attorney-in-Fact acknowledged the said instrument to be the
free act and deed of said corporation.
_______________________________________
(Notarial Seal) Notary Public, St. Louis County, Minn.
My Commission expires ___________________
Approved as to form hereof,
this __________ day of ___________________, 20____.
_____________________________________________
Assistant City Attorney
Duluth, Minnesota
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Boardingkennel Boarding Kennel License Application (City of Duluth)

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Completed 14 July 2020

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