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,ARZEN HILLS BUS06- <br /> 1245 West Hwy 96S <br /> Payment Method <br /> Arden Hills MN 55112 _..........._...._..._._.._________... <br /> P 1.634:5120*Fax rnn.us 4.5137 License/Registration Receipt# ____ <br /> ci.arden-hills.mn.us <br /> Date Paid <br /> Amount <br /> Company Name <br /> Local Address <br /> Local Phone# MN Tax ID# <br /> Local Fax# Federal Tax ID# <br /> Local Contact <br /> Nature of Business <br /> Billing Information(if different from above): <br /> Company Name <br /> Address <br /> City/State/Zip <br /> Contact Name Contact# <br /> fired Submittals: <br /> ■ Payment,see Fee Schedule(enclose check or pay by credit card in person). <br /> ■ Certificate of Liability Insurance of at least$100,000 for bodily injury to any one person,including accidental death,and not <br /> less than$300,000 aggregate;property damage liability of at least$100,000 for each accident and not less than$100,000 <br /> aggregate. <br /> ■ Certificate of Worker's Compensation to the minimum acceptable levels of the State of Minnesota. <br /> OR: Sign Worker's Compensation Waiver: <br /> If you are a sole proprietor and have chosen not to carry worker's comp,the following waiver must be signed: As a sole proprietor or partnership,I/we <br /> have chosen not to cavy Worker's Compensation Insurance on myself/ourselves. <br /> ...............__.._._....__._....._...._......._._..................._......._._._....-- <br /> Authorized Signature Date <br /> Fee Schedule: <br /> Amusement Facility..............................................$100 Drive-thru restaurants.................................................................$300 <br /> Amusement Devices...........$15/location+$15/device All other restaurants.....................$20/1,000 sq.ft.or fraction thereof <br /> Service Station......................................................$100 Sign(renewal fee for permanent signs)................................$20/sign <br /> Bulk Fuel Storage..........................................$200/each Courtesy Bench,non-advertising.......................................$25/bench <br /> Grocery Store...........$20/1,000 sq.ft.or faction thereof Courtesy Bench,advertising..............................................$75/bench <br /> Hotel/Motel......................................................$6/room *Total Fee Owed............$ <br /> Retail Sales..............................................................$50 *If none of the above fees describe your type of business,no fee is <br /> owed for this license/registration. <br /> Applicant Signature _,_.____ Date <br /> "i�� Page 1 of 1 <br />