Fillable Business License Application (City of Fallon)

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Business License Application (City of Fallon)

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BROWSE CITY OF FALLON (NV) FORMS

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CITY OF FALLON CLERK’S OFFICE
55 West Williams Avenue, Fallon, Nevada 89406
Phone: (775) 423-5104
Fax: (775) 423-8874
Business License Checklist - Page 1 of 1
BUSINESS LICENSE CHECKLIST
BUSINESS LICENSE APPLICATION. Please complete the form in its entirety.
Proof of Business Name. Articles of Incorporation, Partnership agreement and/or proof of Fictitious Firm Name
registration. If your business is utilizing a fictitious firm name (DBA), it must be registered with the Churchill County
Clerk/Treasurer’s Office, 155 North Taylor Street, Fallon, Nevada. You will need to provide a copy of your proof of
business name with your application.
STATE BUSINESS LICENSE. You must register with the Nevada Secretary of State for a Nevada state business
license. You may register online at www.nvsilverflume.gov. You may also register in person at the Nevada
Secretary of State, 202 North Carson Street, Carson City, Nevada. If you have questions regarding a Nevada
state business license, please contact them at 775-684-5708. You will need to provide a copy of your State
business license with your application.
SALES AND USE TAX PERMIT. You must register with the Nevada Department of Taxation by completing the
sales and use tax permit registration online at www.nvsilverflume.gov. You may also register in person at the
Nevada Department of Taxation, 4600 Kietzke Lane, Building "L", Suite 235, Reno, Nevada. If you have questions
regarding the sales and use tax permit, please contact them at 866-962-3707. You will need to provide a copy of
your proof of registration with your application.
STATE INDUSTRIAL INSURANCE. You must provide proof Worker's Compensation Insurance or complete a
Nevada Industrial Insurance affirmation of compliance, even if you have no employees. If you have questions,
please contact the Nevada Industrial Insurance, 400 West King Street, Suite 400, Carson City, Nevada or at 775
684-7260. You will need to provide a copy of the proof of coverage or the completed compliance form with your
application.
CERTIFICATE OF PROFESSION. If you have a Certificate of Profession (i.e. Contractor’s License, Child Care,
Practitioner, Liquor distribution/importation, Gaming, DMV registration/license, Cosmetologist, etc.) you will need to
provide proof of any required licenses with your application.
CHILD SUPPORT STATEMENT. You must complete the Child Support Compliance Statement, included in this
packet.
OTHER LICENSING (Liquor, Gaming, Cabaret).
• If your business will be serving or selling alcohol, you must complete the Liquor License Application.
• If your business permits dancing or will be providing live entertainment, you must complete the Cabaret
License Application.
• If your business will be providing gambling games or gambling devices, you must complete the Gaming
License Application.
SOLICITORS PERMIT. If you will be going door to door, you must obtain a Solicitors Permit. This form can be
obtained at the Fallon Police Department.
STATE HEALTH PERMIT. A State Health Permit is required for all businesses handling food, beverages, or
cosmetics. Please contact the Nevada Bureau of Health Protection Services at 775-423-2281 or 775-687-7533.
APPROVALS AND AGENCY SIGN-OFFS. Business License staff will provide you with a sign-off form and
information regarding certain federal, state, county, and city requirements. However, this service is informational
and should not be construed as a final or complete interpretation of legal requirements, which must be obtained
from the appropriate agency. You will be directed to all applicable agencies for final approval. These agencies
may charge fees for any inspections to be made. You must obtain agency approval on the sign-off form before
your license can be issued.
FEES. The business license fee must be paid before your license can be issued.
CITY OF FALLON CLERK’S OFFICE
55 West Williams Avenue, Fallon, Nevada 89406
Phone: (775) 423-5104
Fax: (775) 423-8874
Business License Application - Page 1 of 3
BUSINESS LICENSE APPLICATION
I certify th
at the business stated above, anticipates annual gross sales of:
Annual Gross Receipts
License Fee
Between $0.00 and $24,999.00
$50.00
Between $25,000.00 and $99,999.00
$100.00
Between $100,000.00 and $249,999.00
$150.00
Between $250,000.00 and $499,999.00
$200.00
Between $500,000.00 and $749,999.00
$250.00
Between $750,000.00 and $999,999.00
$300.00
Over $1,000,000.00. For each additional $500,000 of gross receipts, the fee shall be
increased by $125 (Example: $1,768,593.00 = $550.00 License Fee)
TOTAL LICENSE FEE
I declare under penalty of perjury that the foregoing is true and correct:
1. That I have read and reviewed a copy of Chapter 5.04 of the Fallon Municipal Code – Business Licenses;
2. That upon approval of a Business License, I will conduct the business and business establishment in accordance
with the provisions of the laws of the State of Nevada, the United States, and the ordinances of the City of Fallon
applicable to the conduct of business; and
3. That the above information is true and correct to the best of my knowledge and belief and that such declaration is
made with the full knowledge that any failure to disclose, misstatement, or other attempt to mislead may be
considered sufficient cause for denial of a business license.
Applicant’s Signature
New Owner Change Manager Change Name Change Location Change
Last
First
MI
Application Name:
Applicant’s Title :
City
State
Zip
Sole Proprietor
Partnership
DBA
Corporation
Association
Other:
Phone:
Phone:
City
State
Zip
City
State
Zip
Yes No
If “Yes”, you will be subject to the City’s small commercial electric rates.
Business Fax Number:
NV Business License Number:
Nevada Contractor Number:
Business Entity Type:
Business Name:
Business Owner(s):
Business Manager:
Business Address:
Mailing Address:
Is this a Home Based
Business:
Business Phone Number:
Email Address:
Federal Tax ID:
Sales/Use Tax ID:
County Number:
Nature of Business:
Application Type:
Phone:
Date of Application:
Home Address:
Change of Owner, Manager, Name or Location = $5.00 fee
update 8/8/19
CITY OF FALLON CLERK’S OFFICE
55 West Williams Avenue, Fallon, Nevada 89406
Phone: (775) 423-5104
Fax: (775) 423-8874
Business License Application - Page 2 of 3
CHILD SUPP
ORT COMPLIANCE STATEMENT
In compliance with State and Federal law, applicants applying for a Business License are required to complete and submit
this Child Support Information Statement with their Business License Application. Failure to complete this form will be an
automatic denial of any license, certificate or permit that you are applying for.
1. I am not subject to a court order for the support of a child.
2. I am subject to a court order for the support of one or more children and in compliance with the order or in
compliance with a plan approved by the District Attorney or other public agency enforcing the order for
the repayment of the amount owed pursuant to the order.
3. I am subject to a court order for the support of one or more children and NOT in compliance with the
order or a plan approved by the District Attorney or other public agency enforcing the order for the
repayment of the amount owed pursuant to the order. ** Note: If you have marked this response you
should contact the District Attorney or other public agency enforcing the order to determine the actions
that you may take to satisfy the Order.
I certify, under penalty of perjury to the truth and accuracy of all statements contained herein.
Signature:
Printed Name:
Social Security Number:
Date:
CITY OF FALLON CLERK’S OFFICE
55 West Williams Avenue, Fallon, Nevada 89406
Phone: (775) 423-5104
Fax: (775) 423-8874
Business License Application - Page 3 of 3
BUSINESS LI
CENSE
LOCATION APPROVAL FORM
The following signatures indicating compliance with applicable health, safety zones, and building standards must be
secured by the applicant before a City of Fallon business license can be issued.
Office:
Cell:
775-423-5107
775-217-5967
Date:
Office:
775-423-5107
Date:
Office:
Cell:
775-423-0665
775-427-7911
Business Name:
Business Address:
Applicant’s Name:
(24 HOUR NOTICE MAY BE REQUIRED)
City of Fallon Building Department
Gary Johnson, Building Inspector
55 West Williams Avenue, Fallon, Nevada 89406
Approved By:
City of Fallon Engineering Department
55 West Williams Avenue, Fallon, Nevada 89406
Approved By:
City of Fallon/Churchill County Fire Department
Mitch Young, Fire Marshall
20 North Carson Street, Fallon, Nevada 89406
Approved By:
Date:
SALE OF CONSUMABLE ITEMS, MUST BE APPROVED BY THE HEALTH DEPARTMENT
Consumer Health Division
155 North Taylor Street, Suite 103, Fallon, Nevada 89406
775-423-2281
775-687-7571
775-687-7539
Approved By:
Date:
OFFICIAL USE ONLY:
Account No.
License No.
Zone:
Reviewed By:
Payment Received By:
Derek Zimney
STATE OF NEVADA, DIVISION OF INDUSTRIAL RELATIONS
AFFIRMATION OF COMPLIANCE
WITH MANDATORY INDUSTRIAL INSURANCE REQUIREMENTS
(Instructions with Definitions are located on reverse side)
Business Name (Include any name doing business as) Type of Business Business Telephone Number
Business Address Ci
ty State Zip Code
Federal Identification No. Social Security No. Contractor's Board License No.
Nam
e of Principal Ow
ner (Please Prin
t)
Principal Owner's Telephone No.
Principal Ow
ner's Address
City State Z
ip Code
Identified as: (Complete one section only)
( )
That the above identified business has obtained industrial workers' compensation insurance as required by
Chapter 616A to D, inclusive, of the Nevada Revised Statutes (NRS):
Effective Date of Coverage Account Number
( ) That the above identified business is not subject to the provisions of Chapter 616A to D, inclusive, of the
Nevada Revised Statutes, due to a statutory exemption or as a business which has no employees nor hires
any independent contractor or subcontractor.
( ) That the above identified business has a valid certificate of self-insurance pursuant to Chapter 616A to D,
inclusive, of Nevada Revised Statutes.
Effective Date Certificate Number
I declare that I have the authority to act on behalf of the above described business, and am applying for a license to
operate said business as a(n): ( ) Individual ( ) Sole Proprietor ( ) Partnership ( ) Corporation
Name of Applicant (Please Print) Applicant's Telephone No.
Applicant's Residence Address City State Z
ip
Code
I do hereby affirm that the above information is true and correct.
DATED this
day of , 20 .
Signature of Applicant (To be signed in the presence of the business license office employee) Applicant's Title
Witness Signature - (Business License Office Employee) Name of City or County
If unable to sign this document in the presence of a Business License Employee, the Applicant's signature
must be notarized.
SUBSCRIBED and SWORN to before me on this
day of , 20 .
NOTARY PUBL
IC D-25(1)
(rev. 3/01)
INSTRUCTIONS
The provisions of Chapter 616A to D, inclusive, of the Nevada Revised Statutes require every person, firm,
voluntary association, and private corporation, including any public service corporation, which has any person,
subcontractor, or independent contractor, under contract of hire, to obtain industrial insurance coverage in Nevada or
obtain a certificate of self-insurance from the Nevada Commissioner of Insurance. Subcontractors and
independent contractors engaged in the same trade, business, profession or occupation as the hiring person or
business, are by law considered to be employees. One exception to the requirement for industrial insurance is if
you or your business hires no employees, subcontractors or independent contractors. You are not required to obtain
industrial insurance coverage for the following employees: theatrical or stage performers; casual musicians;
household domestics, farm, dairy, agricultural or horticultural laborers, or persons engaged in stock or poultry
raising; voluntary ski patrolman; real estate brokers and/or salesmen; direct sellers; or clergy. Businesses which elect
to obtain industrial insurance coverage for such persons, gain valuable rights and significantly reduce liabilities for
injuries to these persons. A business which hires persons who are exempt from the provisions of Chapter 616A
to 617, inclusive, of the Nevada Revised Statutes may be held liable in tort for injuries to those persons. A
business which hires exempt persons may elect to obtain industrial insurance, including sole proprietor coverage and
partnerships.
IMPORTANT NOTICE: Pursuant to the provisions of NRS 616D.200(1): Any employer within the provisions of
NRS 616B.633 who fails to provide, secure or maintain compensation as required by the terms of this chapter, is: (a)
for the first offense, guilty of a misdemeanor and (b) for a second or subsequent offense committed within 7 years
after the previous offense, guilty of a category D felony.
Definitions for Purposes of this Affirmation:
"Applicant" is the person executing this document.
"Business Name" is the name under which the business will operate, including the identification of any
other names under which the entity will do business.
"Corporation" is a business which is incorporated in the state of Nevada or in any other state, and which is
recognized as an active corporation by the Secretary of State for the State of Nevada.
AType of Business@ means the nature of business . . .
"Individual" is a person who operates a business which hires no employees, subcontractors or independent
contractors.
"Partnership" is a business which is owned and operated by two or more individuals who share ownership
rights to the net profits of the business and who share in all the liabilities of that business. A limited partnership is
included in the term partnership if the limited partners are investors only, and do not perform services for the
business.
"Principal Owner" is the owner, sole operator, designated general partner, or resident agent for the
corporation.
"Sole proprietor" is a self-employed owner of an unincorporated business and includes working partners and
members of working associations which may or may not hire employees.
D-25(2)
(rev. 3/01)
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Business License Application (City of Fallon)

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Completed 14 July 2020

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