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Syntheticdrugest K:\CLERKDOC\LICENSES\Current Licenses\syntheticdrugest_fillable.wpd

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BROWSE CITY OF DULUTH (MN) FORMS

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Page 1 of 2
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.
DATA ADVISORY. The city is collecting this data in order to determine whether the applicant is eligible to be issued a license for the sale of
synthetic drugs. The data are classified as public or private data. The data will be reviewed by city employees responsible for processing the
application, verifying the information, and determining whether the applicant is eligible for a license. The applicant is required to provide the
requested data. If the data is not provided the city may be unable to issue the license. Data that are classified as public are available to the public.
Data that are classified as private may be available to other law enforcement agencies, or state and federal taxing authorities.
LICENSE FEE
SYNTHETIC DRUG ESTABLISHMENT = $143.00
P
LUS $31.00 INITIAL INVESTIGATION FEE (ONE TIME ONLY) = $__________
TOTAL = $__________
NAME OF APPLICANT: ______________________________ ASSUMED NAME: ______________________________
DESCRIPTION OF BUSINESS: ________________________________________ BUS. PHONE: __________________
LOCATION OF THE ESTABLISHMENT [STREET ADDRESS]: ________________________________________________
BUSINESS DISTANCE FROM NEAREST: PUBLIC PARK: _______ SCHOOL: _______ DAYCARE: _______
RESIDENTIAL AND/OR MIXED-USE NEIGHBORHOOD ZONE: __________
BUSINESS OWNER(S) INFORMATION. F
ILL IN THE REQUIRED INFORMATION FOR ALL OWNERS.
Convicted of a
Residential Business Crime or
Full Name DOB Address Address Phone No. Offense? (Y/N)*
PARTNER INFORMATION
(INCLUDING LIMITED PARTNERS). FILL IN THE REQUIRED INFORMATION FOR ALL PARTNERS.
Convicted of a
Residential Business Crime or
Full Name DOB Address Address Phone No. Offense? (Y/N)*
MANAGER INFORMATION. Convicted of a
Residential Business Crime or
Full Name DOB Address Address Phone No. Offense? (Y/N)*
Page 2 of 2
REAL ESTATE OWNER(S) INFORMATION. FILL IN THE REQUIRED INFORMATION FOR ALL OWNERS.
Convicted of a
Residential Business Crime or
Full Name DOB Address Address Phone No. Offense? (Y/N)*
LESSEE(S) INFORMATION. F
ILL IN THE REQUIRED INFORMATION FOR ALL LESSEES.
Convicted of a
Residential Business Crime or
Full Name DOB Address Address Phone No. Offense? (Y/N)*
*IF ANY OF THE ABOVE-LISTED INDIVIDUALS HAVE BEEN CONVICTED OF A CRIME OR OFFENSE
(OTHER THAN A TRAFFIC OFFENSE) FILL IN THE INFORMATION FOR
EACH INDIVIDUAL BELOW.
Disposition of offense
Include the specific state & prosecuting
jurisdiction where disposition of
Description Date of Location offense was adjudicated
Full Name of Offense Offense of Offense & date of adjudication
IF ANY OF THE OWNERS OF THE BUSINESS OR THE BUSINESS ITSELF OWES ANY FEES, CHARGES, TAXES,
SPECIAL ASSESSMENTS AND OTHER DEBTS OR OBLIGATIONS TO THE CITY, FILL IN THE INFORMATION BELOW:
Nature of Debt or Obligation Amount Owed
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: _________________________________________
___________________________________________ S
IGNATURE OF APPLICANT OR APPLICANT’S AGENT
___________________________________________ _________________________________________
PRINTED NAME OF APPLICANT OR APPLICANT’S AGENT
___________________________________________
_________________________________________
I
F AGENT, RELATIONSHIP TO 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)
COUNTY
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)
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 ________________
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Completed 12 July 2020

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