Fillable Business License Application General Information (City of Cottage Grove)

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Business License Application General Information (City of Cottage Grove)

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BROWSE CITY OF COTTAGE GROVE (MN) FORMS

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Business License Application
General Information
Business Trade Name:
Business Address:
Business Telephone:
Applicant Name:
Name of Corporation, Organization, Partnership, or Individual
DOB (if individual)
Applicant Address:
Street Addres s
City, State Zip
Applicant Telephone:
Fax:
Email:
License(s) Applied For—Note: An Additional License Addendum MUST Be Filled Out For Each Specific Business License.
Alarm
Amusement
Fireworks
Gambling – Single Occasion
Lawn Care
Liquor
Massage Business
Massage Therapist
Solid Waste & Recycling
Special Event
Tobacco
Tree Care
Other:
Important
Minnesota Tax ID Number: Federal Employer Identification Number:
The MN Department of Revenue has requested that we provide MN Tax ID and Federal Employer Identification
Numbers to them per Minnesota Statute 270C.72. Please enter your numbers above. If you are an individual applicant
without a MN Tax ID Number or Federal Employer Identification Number, please enter your Social Security Number
or
Individual Taxpayer Identification Number here
:
I certify that the information provided is true and correct, and hereby agree to operate said business in accordance
with the laws of Minnesota and the City Code of the City of Cottage Grove
Applicant Signature and Title: ________________________________________ Date: _______________________
CITY OF COTTAGE GROVE
12800 Ravine Parkway
Cottage Grove, Minnesota 55016
www.cottage-grove.org 651-458-2800 Fax 651-458-2897 Equal Opportunity Employer
✔
CITY OF COTTAGE GROVE
12800 Ravine Parkway
Cottage Grove, Minnesota 55016
www.cottage-grove.org 651-458-2800 Fax 651-458-2897 Equal Opportunity Employer
Massage Therapist
License Addendum
Calendar-year License Fee: $100.00 (initial license prorated quarterly).
Investigation Fee: $100.00 (initial license only).
Please make your check payable to City of Cottage Grove.
Full Legal Name:
Date of Birth:
Name and address of business where you will be employed:
Have you ever been arrested for any crime, felony, misdemeanor or violation of any ordinance other
than a minor traffic offense?
If yes, please explain:
Have you ever held a massage certificate in another community?
If yes, where?
Have you ever had a massage certificate denied, suspended, revoked, or cancelled in any other
community?
If yes, please explain:
Please attach a copy of your diploma or certificate of graduation in Massage Therapy.
“I declare under the penalties of perjury that the foregoing statements are true to the best of my
knowledge and belief.”
Signature: Date:
City of Cottage Grove
Department of Public Safety
General Authorization and Release of Private Data
I hereby authorize and grant my informed consent to permit the Minnesota Bureau of
Criminal Apprehension to release and to make available to the City of Cottage grove,
Minnesota, and/or its agents and/or representative of the following types of private data:
• Criminal History
• Driver’s License records for any and all states for which I have or currently am
licensed
• Arrest Warrant information, including local, statewide and national sources of
information
I understand my rights under Title 5, United States Code Section 552A, and the
Minnesota Data Practices Act with regard to access and disclosure of Private Data. I
hereby knowingly waive those rights with the understanding that information furnished
will be used by the city of Cottage Grove in determining my suitability for licensure.
This authorization shall be valid for a period of one year. I reserve the right to cancel the
written authorization at any time prior to the expiration, by providing written notice to the
City of Cottage Grove of the fact.
I have provided some form of photo identification (ie. Driver’s License, Passport) at time
of application.
Date of Birth
Date
Current Address
City
State
Zip
Daytime Phone Number
Email Address
Revised 2015/08/07
Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
Licensing and Certification Services
443 Lafayette Road North
St. Paul, MN 55155
Mailing Address:
PO Box 64217
St. Paul, MN 55164-0217
E-mail: dli.license@state.mn.us
Web Site: www.dli.mn.gov/ccld.asp
Directions: http://www.dli.mn.gov/Direct.asp
Phone: (651) 284-5034
Certificate of Compliance
Minnesota Workers’ Compensation Law
THIS FORM MUST BE COMPLETED AND SIGNED
BY ALL BUSINESS TYPES
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 a
nd Industry.
A valid workers’ compensation policy must be kept in effect at all times by employers as required by law.
CONTRACTOR’S LICENSE or REGISTRATION 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 NAME
(Doing business as name / assumed name – if applicable
)
BUSINESS ADDRESS (must be physical street address, no PO boxes)
CITY
STATE
ZIP
COUNTY
E-MAIL ADDRESS
YOUR LICENSE OR REGISTRATION WILL NOT BE ISSUED WITHOUT THE FOLLOWING
INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 – Workers’ compensation insurance policy information
INSURANCE COMPANY NAME (not the insurance agent)
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:
I have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee)
I am self-insured for workers’ compensation (include a copy of 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.
APPLICANT SIGNATURE (mandatory) 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. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651)
297-4198.
CC0515 Work Comp Compliance (12/12)
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Business License Application General Information (City of Cottage Grove)

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Completed 12 February 2021

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