Fill - Free fillable Pawnbrokers Application (City of Farmington) PDF form

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CITY OF FARMINGTON

LICENSE PROCESS

Pawnbrokers and Precious Metal Dealers

Following is the process to obtain a license for pawnbrokers or precious metal dealers. All

licenses expire December 31 of each year.

1. Submit application and all appropriate forms and fees.

2. All applications shall be referred to the police department for verification and

investigation of the facts set forth in the application. Within 60 days after receipt of a

complete application, the police department shall make a written report and

recommendation to the City Council as to issuance or non-issuance of the license. The

City Council may order and conduct such additional investigation as it deems necessary.

If additional investigation is necessary, the applicant shall pay the city the cost of the

additional investigation. The license shall not be issued until any additional investigation

costs are paid.

3. A public hearing will be held within 30 days following receipt of the police department’s

report and recommendation.

4. Notice of public hearing shall be published at least 10 days prior to the hearing.

5. Property owners within 500 ft. of the boundaries of the business property shall be notified

by mail 10 days prior to the hearing.

6. The City Council may grant or deny the application within 30 days after the close of the

hearing.

7. If the building is under construction, a license will not be delivered until a certificate of

occupancy has been issued for the licensed premises.

8. Fees: Investigation Fee $1,000

Annual License Fee $8,000/year

Billable Transaction Fee Electronic $1.50/transaction

Billable Transaction Fee Manual $2.50/transaction

If you have questions, please contact:

Cynthia Muller, Administrative Assistant

City of Farmington

430 Third Street

Farmington, MN 55024

Tel: 651-280-6803

CMuller@FarmingtonMN.gov

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Checklist for Pawnbrokers and

Precious Metal Dealers License

Business Name: ________________________________________

Please return this list with your application materials. Incomplete applications cannot be

processed until all of the items listed are received and complete.

Required Applicant City Staff

Documents Initials Initials

1. City of Farmington License Application ____________ ____________

2. Workers’ Comp. Certificate of Compliance (Form FGTN2009)____________ ____________

3. General Authorization and Release of Data __________ __________

4. All applicable Fees (See fee schedule below) ____________ ____________

5. Certificate of liability insurance __________ __________

6. Floor plan of premises __________ __________

Pawnbrokers and Precious Metal Dealers License Fees

Investigation Fee $1,000/year

Annual License Fee $8,000/year

Billable Transaction Fee Electronic $1.50/transaction

Billable Transaction Fee Manual $2.50/transaction

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Pawnbrokers and Precious Metal Dealers Application

1. Individual Owner _________ Partnership ________ Corporation _______

2. Applicant Name: _____________________________________________________________

3. Resident Address: ____________________________________________________________

4. Date of Birth: ____________________ Telephone Number: _______________________

5. Applicant is: ________ a U.S. Citizen or __________ Resident Alien

6. Has the applicant ever used or been known by a name other than the applicant’s name?

_____ No ______ Yes If yes, provide the name or names used and information

concerning dates and places where used ___________________________________________

____________________________________________________________________________

7. Business Name if it is to be conducted under a designation, name, or style other than the name

of the applicant and attach a certified copy of the certificate as required by MSA section 333.01.

____________________________________________________________________________

8. Applicant’s street addresses where applicant has lived during preceding five years.

____________________________________________________________________________

9. Provide the type, name, and location of every business or occupation in which the applicant

has been engaged during the preceding five years and the name(s) and address(es) of the

applicant’s employer(s) and partner(s), if any, for the preceding five years.

___________________________________________________________________________

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10. Has applicant ever been convicted of a felony, crime, or violation of any ordinance other

than a traffic ordinance? _______ No _________ Yes If yes, provide information as

to the time, place, and offense of all such convictions. __________________________________

______________________________________________________________________________

11. Provide a physical description of the applicant ____________________________________

______________________________________________________________________________

12. Provide the applicant’s current personal financial statement and true copies of the

applicant’s federal and state tax returns for the two years prior to application.

13. Minnesota Tax ID Number _____________________________

Federal Tax ID Number ________________________________

14. If applicant does not manage the business, provide the name of the manager(s) or other

person(s) in charge of the business and all information concerning each of them as requested

above with additional applications attached for each ___________________________________

_____________________________________________________________________________

15. Does applicant hold any of the following licenses from any other governmental unit:

____ Pawnbroker ________ Precious Metal Dealer _______ Secondhand Goods Dealer

16. Has the applicant previously been denied or had revoked or suspended the above license(s)

from this or any other governmental unit? ___________________________________________

_____________________________________________________________________________

17. Provide names, street resident addresses, business addresses and telephone numbers of three

individuals who are of good moral character and who are not related to the applicant or not

holding any ownership in the premises or business who may be contacted as to the applicant’s

and/or manager’s character.

Name Business Address Street Address Telephone No.

_______________ ____________________ _________________________ ____________

18. Location of business _________________________________________________________

19. Legal description of the premises to be licensed ___________________________________

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20. Location where applicant’s business records are maintained __________________________

21. If the applicant does not own the licensed premises, attach a true and complete copy of the

executed lease.

22. Have real estate and personal property taxes that are due and payable for the premises to be

licensed been paid? ______ Yes ______ No If not, provide the years and amounts that

are unpaid _____________________________________________________________________

23. If premises construction is being planned, under construction or undergoing substantial

alteration, attached a set of preliminary plans showing the design of the proposed premises to be

licensed. If the plans or design are on file with the City Building Inspections department, no

plans need to be submitted. Plans on file with the City ______ Yes ______ No

If applicant is a partnership:

24. Provide the name(s) and address(es) of all general and limited partners and all information

concerning each general partner as requested above with additional application for each.

_____________________________________________________________________________

25. Provide name(s) of managing partner(s) and the interest of each partner in the pawnbroker or

precious metal business.

Name Interest

_________________________________________________ _________________

26. Attach a true copy of the partnership agreement to this application. If the partnership is

required to file a certificate as to a trade name pursuant to MSA section 333.01, a certified copy

of such certificate shall be attached to the application.

27. Attach a true copy of the federal and state tax returns for partnership for the two years prior

to application.

If applicant is a corporation or other organization:

28. Name of corporation or business form, and if incorporated, the state of incorporation

_____________________________________________________________________________

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29. Attach a true copy of the certificate of incorporation, articles of incorporation, or association

agreement, and bylaws. If applicant is a foreign corporation, a certificate of authority as required

by MSA section 303.06 shall be attached.

30. Name of manager(s), proprietor(s), or other agent(s) in charge of the business and all

information concerning each manager, proprietor, or agent as requested above with additional

application for each. _____________________________________________________________

______________________________________________________________________________

31. List all persons who control or own an interest in excess of 5% in such organization or

business form or who are officers of the corporation or business form and all information

concerning said persons as required above.

Name Interest

_________________________________________________ _________________

______________________________ ____________________ _________________

Applicant Signature Title Date

Subscribed and sworn to before me this _______ day of ______________________ 20____.

___________________________

NOTARY SEAL Notary Public

APPROVALS:

_______________________________________ __________________

Police Department Date

_______________________________________ __________________

City Clerk Date

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CERTIFICATION OF COMPLIANCE

MINNESOTA WORKERS’ COMPENSATION LAW

Form FGTN2009

Minnesota Statute, 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 or engage

in an activity in Minnesota until the applicant presents acceptable evidence of

compliance with the workers’ compensation insurance coverage requirement of Chapter

176. The information required will be collected by the licensing agency and retained in

their files. The information required is: name of insurance company, policy number, and

dates of coverage or permit to self-insure.

This information is required by law, and licenses and permits to operate a

business may not be issued or renewed if it is not provided and/or is falsely

reported. Furthermore, if this information is not provided or falsely stated, it may

result in a $2,000 penalty assessed against the applicant by the Commissioner of

the Department of Labor and Industry.

Insurance Company Name: _____________________________________________

(Not the insurance agent)

Policy Number: _______________________________________________________

Dates of Coverage: ____________________________ to ______________________

(or)

I am not required to have workers’ compensation liability coverage because:

( ) I have no employees.

( ) I am self-insured (include permit to self-insure).

( ) I have no employees who are covered by the workers’ compensation law,

(these include: spouse, parents, children and certain farm employees).

I certify that the information provided above is accurate and complete and that a valid

workers’ compensation policy will be kept in effect at all times as required by law.

Name: ________________________________________________________________

(Last) (Middle) (First)

Doing business as (DBA): _______________________________________________

(Business name if different than your name)

Business address: _____________________________________________________

(Street) (City, State, ZIP)

Phone: _________________________ Email: ________________________________

Signature: _______________________________________Date: ________________

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176.182 BUSINESS LICENSES OR PERMITS; COVERAGE REQUIRED

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 Section 176.181, subdivision 2, by providing the name of the insurance

company, the policy number, and the dates of coverage or the permit to self-insure.

The commissioner shall assess a penalty to the employer of $2,000 payable to the

assigned risk safety account, it the information is not reported or is falsely reported.

Neither the state nor any governmental subdivision of the state shall enter into

any contract for the doing of any public work before receiving from all other contracting

parties acceptable evidence of compliance with the workers’ compensation insurance

coverage requirement of Section 176.181, subdivision 2.

This section shall not be construed to create any liability on the part of the state

or any governmental subdivision to pay workers’ compensation benefits or to indemnify

the special compensation fund, an employer, or insurer who pays workers’

compensation benefits.

HIST: 1982 c 346 s 94; 1983 c 290 s 114; 1987 c 332 c 332 s 47; 1992 c 510 art 3 s 19;

1995 c 231 art 2 s 72

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CITY OF FARMINGTON

GENERAL AUTHORIZATION AND RELEASE OF DATA

In order to comply with State and Federal Data Privacy Act Laws, the City of Farmington is

requesting your authorization and consent to permit the City to conduct a background

investigation. Please provide the following personal data, read the paragraphs below and sign

where indicated.

Full Name: ____________________________________________________________________

(First, Middle, Last)

Address: ______________________________________________________________________

Number Street City County State Zip Code

Date of Birth: _________________ Driver’s License Number: __________________________

Month/Date/Year

Have you ever been convicted of any crime, either felony or misdemeanor? ________ If yes,

please state place and nature of offense: _____________________________________________

______________________________________________________________________________

I, the undersigned, hereby authorize and grant my informed consent to permit the Bureau of

Criminal Apprehension (hereafter “BCA”) and the Farmington Police Department (hereafter

“FPD”) to release to and make available to the City of Farmington, Minnesota (hereafter “City”)

and/or its representatives all data classified as private which concerns me and which may be in

your possession. The data, classified as private under M.S. 13.02, Subd. 12, includes all data

which has been collected, created, received, retained or disseminated in whatever form which in

any way relates to my dealings with the BCA and/or the FPD. I understand the purpose of

permitting the City to have access to this information is to determine my suitability for licensure.

By signing this authorization, I hereby release the BCA and the FPD from any and all liability

which otherwise may or does accrue as a result of the release of any and all data, regardless of its

accuracy. I also release the City from any and all liability for its receipt and use of data received

pursuant to this consent. I understand that if I am rejected on the basis of a criminal conviction, I

will be notified in writing and be given rights of redress subject to applicable laws. I also

understand that I am not legally required to sign this form, but if I do not, the City will not be

able to determine whether my conviction record is a license-related consideration.

This authorization shall be valid for a period of one year, but I reserve the right, at any time prior

to that expiration, to cancel the written authorization by providing written notice to the City of

that intent.

_______________________________________________ ________________________

(Signature) (Date)

_______________________________________________

(Full Name Printed)

Please return to:

City of Farmington, Attn: Administration

430 Third Street, Farmington, MN 55024

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CITY OF FARMINGTON – DATA PRACTICES ACT NOTICE

Minnesota law requires that you be informed of your rights as they pertain to private information

(“private data”) collected from you by the City of Farmington (“the City”). Private data is that

information held by the City which is available to you, but not to the public.

You have the right to refuse to provide the information requested on this application form,

however, without certain information, the City may be unable to approve the license applied for.

If you feel that certain information requested is an unwarranted invasion of privacy, please

contact the Human Resources Director.

The dissemination and the use of private data we collect is limited to that necessary for the

administration and management of the City’s licensing program. Persons or agencies with whom

this information may be shared include:

 City personnel, including law enforcement personnel, administering the license program;

 The Bureau of Criminal Apprehension;

 The City Attorney and support staff of the City Attorney’s office;

 Federal, state, local, and contracted private auditors;

 Federal and State agencies with oversight or responsibility related to the licensed

business;

 Those individuals or agencies as to whom you give your express written permission for

release of the information.

Unless otherwise authorized by state statute or federal law, other governmental agencies utilizing

the reported private data must also treat the information as private.

You may wish to exercise your rights as contained in the Minnesota Government Data Practices

Act. These rights include:

 The right to see and obtain copies of data maintained about you;

 The right to be told the contents and meaning of the data; and

 The right to contest the accuracy and completeness of the data.

To exercise these rights, contact the Farmington Human Resources Director at 430 Third Street,

Farmington, MN 55024 (651) 280-6800. I have read and I understand the above information

regarding my rights as a subject of government data.

___________________________________________ _______________________

Applicant Date

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