Fillable Garbage License Application (City of Duluth)

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Garbage 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 all pages 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.
LICENSE TOTAL FEE
GARBAGE COLLECTOR - $298.00 PER GARBAGE & RECYCLE TRUCK =
$_____________
LICENSEE BUSINESS NAME & ADDRESS
__________________________________________
__________________________________________
__________________________________________
MANAGER’S NAME/ADDRESS/PHONE NO.
__________________________________________
__________________________________________
__________________________________________
__________________________________________
TRADE NAME: ____________________________
BUSINESS PHONE:_________________________
- - -
LICENSE PERIOD: MAY 1 TO APRIL 30
- - -
WORKERS COMPENSATION COMPANY
NAME: ___________________________________
POLICY NO. _______________________________
EXP. DATE _______________________________
REQUIREMENTS:BOND
INSURANCE
INSPECTION REPORTS FROM MN/DOT
BASE RATE FORM FILED
I HEREBY STATE THAT ALL INFORMATION HERE IS TRUE AND CORRECT AND THAT I SHALL
COMPLY WITH ALL PROVISION OF THE ORDINANCES OF THE CITY OF DULUTH AND LAWS OF
THE STATE OF MINNESOTA AND THEIR AMENDMENTS.
_____________________________________________
Signature of Applicant
MAILING ADDRESS:
________________________________
________________________________
________________________________
CITY OF DULUTH
SUPPLEMENTAL DATA FORM
APPLICATION FOR SOLID WASTE COLLECTORS SERVICE LICENSE
City Clerk’s Office - 330 City Hall - Duluth, MN 55802
_____________________________ __________________________________ ________________
TRADE NAME BUSINESS ADDRESS PHONE NUMBER
List below each of the vehicles that will be used for the collection of solid waste, pursuant to this license.
Make Year Cab Color Lic. G.V.W. Mfg Serial # MN Lic. No.
FOR OFFICE USE ONLY:
SOLID WASTE COLLECTION I.D. # ______________________________________ (for all trucks)
Total No. Vehicle I.D. Plates Issued ________________ I.D. Plate # Issued __________________
License No. ___________________
I understand that the vehicle I.D. plates issued pursuant to this license remain the property of the City
of Duluth, and must be returned to the Office of the City Clerk should the Solid Waste Collection license
under which they have been issued, be revoked, suspended, cancelled, denied, or not renewed, and the
fees paid on or before its expiration date.
I also certify under penalty of perjury that the information shown above is true and correct.
Date _______________________ Signature _____________________________________________
To: City Clerk
Subject: Solid Waste Base Rate
Section 24-21 of the Duluth City Code requires that licensed solid waste haulers file their
base rate with the city clerk 30 days before the rate takes effect. The approved rate
structure is as follows:
Service Level Percent of Base Rate
One 20-gallon can once every other week 50%
One 20-gallon can every week 70%
One 32-gallon can every week “Base Rate” 100%
Two 32-gallon cans every week 135%
Three 32-gallon cans every week 170%
Each additional 32-gallon can every week +30%
Extra solid waste up to 20-gallons +10%
A. _______________________________ hereby sets it’s base rate at $___________.
Trade Name
Effective Date _______________________________ (30 days after notice).
___________________________________________________ ______________
Authorized Signature Date
B. As of this date, there are NO CHANGES to the previously filed base rate.
______________________________________ ______________________ ________
Authorized Signature Trade Name Date
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.
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
INSURANCE COMPANY NAME (not the insurance agent)
POLICY NO.
EFFECTIVE 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
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._____________
GARBAGE COLLECTOR CORPORATE SURETY BOND
CITY OF DULUTH ST. LOUIS COUNTY STATE OF MINNESOTA
KNOW ALL MEN BY THESE PRESENTS:
THAT _______________________________________________ of the City of Duluth, in the County of
St. Louis, and State of Minnesota, as Principal, and ___________________________________________________,
a corporation organized under the laws of the State of _____________________ and holding a certificate of the
Insurance Commissioner of the State of Minnesota showing that it is authorized to contract as a surety, as surety, are
held and firmly bound, jointly and severally, unto the City of Duluth, in the State of Minnesota, in the sum of ONE
THOUSAND DOLLARS ($1,000) good and lawful money of the United States, to be paid to the said City of Duluth,
for the use of said city, for which payment in full, well, and truly to be made, we do bind ourselves, our heirs, executors
and administrators, successors or assigns, jointly severally, firmly by these presents.
WHEREAS, the above bounded principal has made application to the City of Duluth for a license to engage
in the business of collecting or removal of solid waste and recyclables according to the provisions of Chapter 24 of
the Duluth City Code, 1959, as amended.
NOW THEREFORE, the conditions of the above obligation is such that if the City Council of Duluth shall issue
a license to the above principal, and if the above principal shall in all things and at all times faithfully comply with the
provisions of the ordinance above referred to, and/or such other ordinance or ordinances which may hereafter be
passed by the City Council of the City of Duluth referring or relating to the collection and removal of solid waste and
recyclables then the above obligation shall be void; otherwise this obligation shall remain in full force and effect.
This bond shall be effective and run concurrently with the period of the aforesaid license. The license period
begins May 1, 2___, and ends April 30, 2____.
Signed this ______day of __________________________, 2____.
Signed, sealed and delivered in the presence of:
(As to Principal)
______________________________________ ___________________________________________
Principal
______________________________________
(As to Surety)
____________________________________ (Seal)
______________________________________ Surety
______________________________________ By:_______________________________________
Attorney in Fact
Countersigned by ____________________________
Minnesota Resident Agent (If required)
ACKNOWLEDGMENT OF PRINCIPAL (INDIVIDUAL)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this day of , 2 , before me personally appeared
___________________________________________ to me known to be the person described in and who
executed the foregoing bond as Principal, and acknowledged that she/he executed the same as her/his
free act and deed.
__________________________________
Notary Public, St. Louis County, Minnesota
(Notarial Seal) My Commission expires ______________
ACKNOWLEDGMENT OF PRINCIPAL (PARTNERSHIP)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this day of , 2 , 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, Minnesota
(Notarial Seal) My Commission expires ______________
ACKNOWLEDGMENT OF PRINCIPAL (CORPORATION)
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this day of , 2 , before me 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, Minnesota
(Notarial Seal) My Commission expires ______________
ACKNOWLEDGMENT OF CORPORATE SURETY
STATE OF MINNESOTA )
ss
COUNTY OF ST. LOUIS )
On this day of , 2 , 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.
__________________________________
Notary Public, St. Louis County, Minnesota
(Notarial Seal) My Commission expires ______________
Approved as to form hereof,
this day of , 2_____.
Assistant City Attorney
Duluth, Minnesota
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Garbage License Application (City of Duluth)

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Completed 20 July 2020

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