HomeMy WebLinkAbout8 -Waste Hauler Application651-747-3900
3880 Laverne Avenue North
Lake Elmo, MN 55042
SOLID WASTE HAULER APPLICATION
Application documents will be reviewed for compliance with the requirements of the City Code. The non-refundable License Fee of covers the license for the
year. Checks should be made payable to the City of Lake Elmo and presented/mailed with this application form to the above address.
License(s) Applied For:
Residential
Commercial
Business Name ______________________________ Contact Person ______________________________________
Business Address _______________________________________________________________________________
City _______________________________ State _________ Zip ____________ Phone ________________________
Business Owner Name: __________________________________________________________________________
Business Owner Address _________________________________________________________________________
City _______________________________ State _________ Zip ____________ Phone ________________________
Minnesota Tax ID# ___________________ Federal Tax ID # _______________
If Minnesota tax identification number is not required, please explain:
_____________________________________________________________________________________________
DATA PRIVACY NOTICE: The data you supply on this form will be used to assess your qualifications for the license. You are not legally required to provide
this data, but we will not be able to grant the license without it. If a license is granted, the data you have supplied will constitute a public record and copies
may be issued to anyone requesting them. The required data allows us to distinguish you from other applicants; to identify you in our license files; to verify
that you are the person who applied for the license to contact you if any additional information is required; to determine whether you meet any minimum age
requirements; and to determine if any conviction you may have on record might affect you suitability as a license holder. Your residence address and telephone number will be considered public data unless you request this information to be private and provide an alternative address and telephone number. (See below)
Please sign below to indicate that you have read this notice.
Signature: _________________________________________________________________________________________________________________
To request that your residence address and telephone number be considered private data, you must list your alternative address and telephone number below:
Address: ____________________________________________________________________ Telephone Number: _____________________________
FOR OFFICE USE ONLY
City Clerk/City Official: _________________________________________________________ Date: _________________________________________
CC0515 Work Comp Compliance (12/11)
Minnesota Department of Labor and Industry
Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North
St. Paul, MN 55155 Phone: (651) 284-5034 Fax: (651) 284-5743
www.dli.mn.gov dli.license@state.mn.us
Certificate of Compliance
Minnesota Workers’
Compensation Law
THIS FORM MUST BE COMPLETED AND SIGNED BY ALL BUSINESS TYPES
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.
CONTRACTOR’S 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) CITY
STATE ZIP
COUNTY E-MAIL ADDRESS
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:
I have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee.)
I am self-insured for workers’ compensation (include a copy of 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.
APPLICANT SIGNATURE (mandatory) 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. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.