Fillable TransientMerchantPermit2019Fillable CITY OF FARMINGTON

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TransientMerchantPermit2019Fillable CITY OF FARMINGTON

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Application for Transient Merchant Permit
APPLICANT INFORMATION
Applicant Name: _______________________________________________________________
(First) (Middle) (Last)
Address: ______________________________________________________________________
(Street) (City, State, Zip)
Home Phone: _________________ Daytime Phone _______________ Cell ______________
Date of Birth: _______________________
Have you ever been convicted of a crime? ___Yes ____No If yes, give details ___________
______________________________________________________________________________
BUSINESS INFORMATION
Business Name/Organization: _____________________________________________________
Address: ______________________________________________________________________
(Street) (City, State, Zip)
Business Phone: _______________ Fax: _____________ Email: ________________________
Product to be sold: ______________________________________________________________
Term of License: 1 year ($65) ___________ 6 Months ($45) _________________
List home addresses for the past five (5) years:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List the year, make, color and registration numbers of all vehicles to be used in conjunction with
this license: ____________________________________________________________________
______________________________________________________________________________
License Number(s) ______________________________________________________________
I hereby certify that all statements made in this application are true and complete to the best of
my knowledge. I understand that any misstatements or omissions of material facts may result in
the disqualification or denial of the license. I authorize the City of Farmington to investigate the
information and contact persons/organizations named on this application.
Name of Applicant: ____________________________________________________________
(Please print)
Signature: ________________________________________________ Date: ____________
THIS SECTION FOR OFFICE USE ONLY
Date Application Received: _________________
Date Fees Paid: ____________________
APPROVALS
APPROVED DISAPPROVED
Police Signature: ______________________________________ Date: ______________
City Administrator: ____________________________________ Date: ______________
Comments: _______________________________________________________________
__________________________________________________________________________
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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: Police Department
19500 Municipal Drive
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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TransientMerchantPermit2019Fillable CITY OF FARMINGTON

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Completed 12 July 2020

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