Fillable STEARNS COUNTY YOUTH CAMP LICENSE APPLICATION 705 Courthouse (Minnesota Department of Revenue)

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STEARNS COUNTY YOUTH CAMP LICENSE APPLICATION 705 Courthouse (Minnesota Department of Revenue)

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The STEARNS COUNTY YOUTH CAMP LICENSE APPLICATION 705 Courthouse (Minnesota Department of Revenue) form is 3 pages long and contains:

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  • 19 check-boxes
  • 91 other fields

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File type: PDF

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BROWSE MINNESOTA DEPARTMENT OF REVENUE FORMS

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M
innesota Law requires that a license is issued prior to operation. Contact Stearns County Environmental Health
Department for assistance.
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
YOUTH CAMP
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
Operating Information
P
roposed Opening Date: ___________________ ❏ Year-Round ❏ Seasonal
If, Seasonal Months Open: ___________________________________________________________________________________
Hours: ❏ Monday _____________ ❏ Tuesday _____________ ❏ Wednesday ____________
_
❏ Thursday _____________ ❏ Friday _____________ ❏ Saturday _____________ ❏ Sunday ______________
Certified Food Manager: _________________________________ FM#: _______________________ Expiration Date: ____________________
Emergency Contact: _____________________________________________________ Phone: ______________________________________________
Type & Capacity Of Facility
❏ Total # of Sites __________ Of these sites how many are RV sites _______ Camping Cabins _______ Empty Lots _______
Facility capacity, max occupancy: ______________
Additional Amenities
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
Food Service or ❏ YES ❏ NO If YES, call Stearns County to determine licensing requirements
Retail Food Sales
Lodging: ❏ YES ❏ N
O
If YES, complete a Lodging Plan Review with Stearns County and
then after approval, submit a Lodging License Application.
(Hotel/Motel/Resort/Vacation Home Rentals)
Annual License Fees
$335.00 (base fee) + $5 (_______# of sites/lots) = ________ Maximum Fee of $850
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.
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 #: _________ ❏ Credit Card
EH Approval: _________________ Effective Date: _________________ Risk: ❏ High ❏ Medium ❏ Low
License Issued: ❏ Postal Mail ❏ E-mail ❏ Hand Delivered
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STEARNS COUNTY YOUTH CAMP LICENSE APPLICATION 705 Courthouse (Minnesota Department of Revenue)

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Completed 18 July 2020

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