Fillable Gasoline License Application (City of Duluth)

Fill Online, Printable, Fillable, Blank Gasoline License Application (City of Duluth) Form

Use Fill to complete blank online CITY OF DULUTH (MN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Gasoline License Application (City of Duluth)

On average this form takes 15 minutes to complete

The Gasoline License Application (City of Duluth) form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Duluth

BROWSE CITY OF DULUTH (MN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 FEE
GASOLINE FILLING STATION (SEE FEE CALCULATION BELOW) =
$___________________
$31.00 INITIAL INVESTIGATION FEE IF APPLICABLE (ONE TIME) = $___________________
TOTAL = $___________________
FEE CALCULATION
! $72.00 - First distribution unit
! $17.00 - Each additional distribution unit
! $119.00 - Initial service inspection fee
! $83.00 - New construction during license year
LICENSEE NAME/ADDRESS/PHONE NO.
__________________________________________
__________________________________________
__________________________________________
MANAGER’S NAME/ADDRESS/PHONE NO.
__________________________________________
__________________________________________
__________________________________________
WORKERS COMPENSATION COMPANY
NAME: _________________________________
POLICY NO. _________________________________
EXP. DATE _________________________________
TRADE NAME: ____________________________
BUSINESS PHONE: _________________________
OWNER OF BUSINESS PREMISES:
__________________________________________
__________________________________________
__________________________________________
- - -
LICENSE PERIOD: MAY 1 TO APRIL 30
- - -
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 ________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Gasoline License Application (City of Duluth)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document