Fillable STEARNS COUNTY MANUNFACTURED HOME PARK LICENSE APPLICATION (Minnesota Department of Revenue)

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STEARNS COUNTY MANUNFACTURED HOME PARK LICENSE APPLICATION (Minnesota Department of Revenue)

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Minnesota Law requires that a license be issued prior to operation. Contact Stearns County Environmental
Health Department for assistance. Change of ownership: Application for License of the Manufactured Home Park
is required to be submitted 30 days prior to taking over operation of the manufactured home park.
Reason for Application (Licenses are not transferable)
❏ N
ew Business ❏ Ownership Change & Date of Change: ______________________
_
If Ownership Change, provide previous name: _____________________________________________________________________________
Business/Facility Identification
Name as it will appear on business: ___________________________________________________________________________________________
Business as Registered with MN Dept. of Revenue: __________________________________________________________________________
MN Tax ID (Required): ___ ___ -___ ___ ___ ___ ___ FEIN (Optional): ___ ___ - ___ ___ ___ ___ ___ ___ ___
Property Address: _________________________________________ City: __ State: _______ Zip: _________________
Property Parcel No: _______________________________________ Township: ________________________________________________________
Mailing Address: __________________________________________ City: ________ ___ State: __ Zip: _________________
Phone: ____ ______ _ ____ _______________________ E-mail: _____________________________________________________________
Licensee/Owner Identification
Name: __________________________________________ Social Security / Individual Taxpayer ID number is required on attached form.
Address: _______________________________________ _City: ___________ ____ State: ____ Zip: ______________________
Phone: ________________________________________________________ E-mail: ______________________________________________________________
Mailing Address: __________________________________________ City: ___________ State: _ _ Zip: _________________
Contact person for establishment: ________ __________ Phone: ________________________________________
Contact person E-mail: ____________________________________________ Relationship to Owner: _____________________________________
If Corporation, Name of Officers: ______________________________________________ ______________________________________________
_______________________________________________ _____________________________________________
_______________________________________________ _____________________________________________
If Management Company Name: ______________________________________________ Phone: _______________________________________
Mailing Address: __________________________________________ City: _______________________State:___________ Zip: _________________
Phone: __________________________________________________________ E-mail: ____________________________________________________________
Billing Mailing address: ❏ Business ❏ Licensee/Owner or ❏ Management Company
STEARNS COUNTY
MANUNFACTURED HOME PARK
LICENSE APPLICATION
705 Courthouse Square - Room 343, St Cloud - MN - 56303
320-656-3613 - 800-450-0852 - Fax 320-656-6484
Water and Wastewater Systems
❏ Onsite sewage treatment system ❏ Municipal sewage system
❏ Onsite water w
ell
❏ Municipal water supply
Local Caretaker Information:
Name (must be available at all times): ____________________________________________________________________________
Phone: ___________________________________________________ E-mail: ____________________________________________________
Caretaker’s Address: _____________________________________________ City: ______________________ State: _______ Zip:______________
Location of posted evacuation plan: ______________________________________________________________________________________________
Type & Capacity Of Homes
Total number of lots: ____________ Number of vacant lots: _____________ Number of owner occupied lots: _____________
Rental homes, provide lot numbers ___________ ___________ ___________ ___________ ___________ ___________ ___________
___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
Additional Amenities
Public Pool or Spa: ❏ YES ❏ NO If YES, complete a Plan Review with MDH and then after the plan
Approval. Submit a Pool License Application with Stearns County.
Ensure To Include
❏
Site Map indicating lot numbers and street addresses
❏ List of all manufactured homes in the park, updated annually, during renewal to County Assessor’s Dept
-Location, lot number and address
-Name of owner of manufactured home and mailing address
-Name of the manufactured home occupant, if different from the owner, and mailing address
-Make, size, year of manufacture of the manufactured home
-Vehicle identification number for the manufactured home and a copy of Certificate of Title, (purchas
e
agreement or the bill of sale)
-Record of payment to Minnesota Manufactured Home Relocation Trust Fund
❏ List of all manufactured homes in park owner’s inventory, including those available for purchase or
rental, updated annually during renewal
❏ Copy of the manufactured home park owner and/or operator’s dealer or limited dealer license
❏ Copy of severe weather shelter and evacuation plan
Annual License Fees
$335.00 (base fee) + $5 (_______# of lots) = __________ Maximum Fee of $950
Total due from above payable to Stearns County = ________________
OPERATING WITHOUT A LICENSE IS PROHIBITED AND WILL RESULT IN A FEE OF $135.00
Fee Exempt: Establishments owned or operated by Stearns County, a school district or other local unit of government.
License Renewal: Renewals are due to the Environmental Service Department and the Assessors Department no
later than January 1
st
each year. If there are questions about the Assessors renewal process contact that
Department.
Declaration
I declare that this information is correct. I agree to comply with the laws and rules of the State of Minnesota and
Stearns County. I understand that failure to comply with the laws and rules may result in delays in issuing my
license to operate.
Applicant’s Signature: ______________________________________________________________________ Date: ________________
Applicant’s Printed Name: _________________________________________________________________
Completed applications, including all supporting materials are to be submitted with payment to Stearns County
Environmental Health Division, Administrative Center, 705 Courthouse Square Room 343, St. Cloud, MN 56303.
Payment can also be made by submitting completed documents by email to foodbeverage@co.stearns.mn.us and
calling our office with credit card information
FOR OFFICE USE ONLY
Receipt #: __________________ Amount Received: ________________ ❏ Check or ❏ Credit Card
EH Approval: _________________ Effective Date: _________________ License Issued Date: _____________________
License Issued: ❏ Postal Mail ❏ E-mail ❏ Hand Delivered
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Every Licensee or Applicant is required to provide a “Social Security” or “Individual Taxpayer
Identification” Number. It is considered private data and will be treated as such as required by
law.
Date:
Establishment Name: ________________________________________
Establishment Address: ______________________________________
City: _____________________________ State: _____ Zip: __________
Applicant (1) Name: _____________________________________________________________
Applicant (1) ID #: _______
________________________ Social Security or Individual Tax ID
App
licant (2) Name: _____________________________________________________________
Applicant (2) ID #: _______________________________ Social Security or Individual Tax ID
App
licant (3) Name: _____________________________________________________________
Applicant (3) ID #: _______
________________________ Social Security or
Individual Tax ID
App
licant (4) Name: _____________________________________________________________
Applicant (4) ID #: _______
________________________ Social Security or Individual Tax ID
The Minnesota Data Practices Act at Minn. Stat. 13.04, Subd. 2, Tennessen warning, states: “An individual
asked to supply private or confidential data concerning the individual shall be informed of: (a) the purpose and
intended use of the requested data within the collecting government entity; (b) whether the individual may refuse or
is legally required to supply the requested data; (c) any known consequence arising from supplying or refusing to
supply private or confidential data; and (d) the identity of other persons or entities authorized by state or federal law
to receive the data.”
Mi
nnesota Statute 270.C.72, Subd. 4, stated that licensing authorities must require applicants to provide their
Social Security number or individual taxpayer identification number and Minnesota business identification number,
as applicable, on all license applications. That information, as well as the name, address, business name and address
of applicants, is made available to the Minnesota Commissioner of Revenue.
YOUR APPLICATION IS INCOMPLETE IF YOU FAIL TO SUPPLY THIS INFORMATION.
This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales,
employer’s withholding or motor vehicle excise taxes. The Minnesota Department of Revenue, in accordance with the
Federal Exchange of Information Act, may supply the information to the Internal Revenue Service.
LIC 04 (11/16)
Certificate of Compliance
Minnesota Workers’ Compensation Law
This form must be completed by the business license applicant.
Print in ink or type
Minnesota Statutes § 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 Minn. Stat. 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.
Business telephone number
Alternate telephone number
Business name (Provide the legal name of the business entity. If the business is a sole proprietor or partnership, provide the owner’s
name(s), for example John Doe, or John Doe and Jane Doe.)
DBA (“doing business as” or “also known as” an assumed name), if applicable
City
State
ZIP code
Email address
You must complete number 1 or 2 below.
Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes.
1. I have a workers’ compensation insurance policy.
Insurance company name (not the insurance agent)
Policy number
Effective date
Expiration date
I am self-insured for workers’ compensation. (Attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.)
2. I am not required to have workers’ compensation insurance because:
I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and messenger
courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other
industries.)
I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition
of an employee.)
I use independent contractors and I have employees who are not required to be covered by the workers’
compensation law. (Explain below.)
I only have employees who are not required to be covered by the workers’ compensation law. (Explain below.) (See
Minn. Stat. § 176.041 for a list of excluded employees.)
Explain why your employees are not required to be covered
I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am
authorized to sign on behalf of the business.
Print name
Applicant signature (required)
Title
Date
If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or
1-800-342-5354.
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STEARNS COUNTY MANUNFACTURED HOME PARK LICENSE APPLICATION (Minnesota Department of Revenue)

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Completed 18 July 2020

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