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
✔
Mobile Food Unit
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
MOBILE FOOD UNIT LICENSE ADDENDUM
$25.00 <= 10 Days Total in the Calendar Year Note: Applicant may only be issued one
temporary license per calendar year.
$100.00 >10 Days Total in the Calendar Year
Please provide the following information:
1. A description of the nature of the business and the goods to be sold and the license plate number
and description for any vehicle to be used in conjunction with the activity;
2. The name of the operator, if different than the owner, of the mobile food unit and the name of all
persons working for the owner and operator of the mobile food unit;
3. The applicant’s full legal name, other names the applicant uses or is known by, date of birth and
driver’s license number, or other legal identification with a photograph of the applicant;
4. The permanent and any temporary home and business address, phone numbers, and email address
of the applicant, with a designation of a preferred mailing address for notices related to the license;
5. The name, address, and contact information for the commissary with which the mobile food unit is
affiliated, if applicable;
6. If owner is an LLC or other similar business entity, the name of the business entity, all other names
that the entity conducts business as, and all of the applicable information required of an individual
applicant for the business entity;
Please attach:
7. A certificate of insurance by an insurance company authorized to do business in the State of
Minnesota, evidencing the following forms of insurance:
a. Commercial general liability insurance, with a limit of not less than one million dollars ($1,000,000) each
occurrence. If such insurance contains an annual aggregate limit, the annual aggregate limit shall be not
less than two million dollars ($2,000,000);
b. Automobile liability insurance with a limit of not less than two million dollars ($2,000,000) combined
single limit. The insurance shall cover liability arising out of any auto, including owned, hired, and non-
owned vehicles;
c. Food products liability insurance, with a limit of not less than one million dollars ($1,000,000) each
occurrence;
d. Public liability insurance, with a limit of not less than one million dollars ($1,000,000) each occurrence;
e. Property damage insurance, with a limit of not less than one million dollars ($1,000,000) each
occurrence;
f. Workers compensation insurance (statutory limits) or evidence of exemption from state law; and
g. The city shall be endorsed as an additional insured on the certificate of insurance and the
umbrella/excess insurance if the applicant intends to operate its mobile food unit on public property,
including public right-of-way.
8. The certificate of insurance must contain a provision requiring notification be sent to the city should
the policy be cancelled before its stated expiration date;
9. Written consent of each private property owner from which mobile food unit sales will be
conducted;
10. If the mobile food unit will be located on city property or public right-of-way, a signed statement
that the licensee shall hold harmless the city and its officers and employees, and shall indemnify the
city and its officers and employees for any claims for damage to property or injury to persons which
may be occasioned by any activity carried on under the terms of the license;
11. If applying only for a temporary license, the applicant must provide the exact dates and locations for
its up to ten (10) days of mobile food unit operations;
12. A copy of each related license or permit issued by Washington County and the state required to
operate a mobile food unit; and
13. A copy of the applicant’s state sales tax ID number.
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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