Form AG-00812 "Application for General Merchandise Warehouse License" - Minnesota

What Is Form AG-00812?

This is a legal form that was released by the Minnesota Department of Agriculture - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Minnesota Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AG-00812 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG-00812 "Application for General Merchandise Warehouse License" - Minnesota

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Plant Protection Division, Ph. 651-201-6011
Entity ID:
Minn. Stat. Ch. 231
20___ APPLICATION FOR GENERAL MERCHANDISE WAREHOUSE LICENSE
Excludes Grain
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must provide your social security number
(MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license without it. No one will have access to your social security number except those
permitted access by law, your written consent, court order, or those department employees whose job duties require access. If you are unsure if you need a Minnesota Tax ID,
contact the Minnesota Department of Revenue at www.taxes.state.mn.us.
Legal Name
MN Tax ID or if none, Social Security
DBA (if different)
Mailing Address (if different):
Physical Street Address (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
Workers' Compensation:
Do you have any paid or otherwise compensated employees in Minnesota?
Yes
No If yes, complete the following information:
Insurance Company Name:
Effective Date:
Expiration Date:
Policy #:
You must provide acceptable evidence of compliance with the Workers' Compensation Insurance Law (MS Sec 176.182). If you are self-insured, attach a copy of the exemption
order from the Commissioner of Commerce authorizing self-insurance. For questions, contact the Minnesota Department of Labor and Industry at www.doli.state.mn.us.
Type of Warehouse:
Wood
Steel
Concrete
Other:
Equipment in the Warehouse:
Types of goods, wares, or merchandise intended to be stored:
Do you store:
Food
Fertilizer
Chemicals
Household Goods
(Attach additional sheets if necessary)
Licensed Locations:
License Number
License Fee:
County
Sq. Footage
Address
(for office use only)
600508(3100)
City/Zip
$
$
$
Bond Requirements:
If you store household goods, a General Merchandise Storage Bond in the
amount of at least $10,000 (per city) must be issued and a tariff must be filed.
License Fee
If you do NOT store household goods, $50,000 warehouseman's legal
Building Sq. Footage
Fee
liability insurance may be filed in place of the General Merchanside Storage
Less than 5,000
$110
If you store household goods, you must attach a copy of your current tariff
5,001 to 10,000
$220
showing rates and charges assessed before your license will be granted.
10,0001 to 20,000
$330
20,001 to 100,000
$440
Return this form with your check made payable to:
MINNESOTA DEPARTMENT OF AGRICULTURE
100,001 to 200,000
$550
Attn: Cashier
Over 200,000
$660
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable and fees are not refundable.
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651/201-6000. TTY users can
call the Minnesota Relay Service at 711 or 1-800-627-3529. The MDA is an equal opportunity employer and provider.
AG-00812 (01/11)
Page 1 of 1
Plant Protection Division, Ph. 651-201-6011
Entity ID:
Minn. Stat. Ch. 231
20___ APPLICATION FOR GENERAL MERCHANDISE WAREHOUSE LICENSE
Excludes Grain
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must provide your social security number
(MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license without it. No one will have access to your social security number except those
permitted access by law, your written consent, court order, or those department employees whose job duties require access. If you are unsure if you need a Minnesota Tax ID,
contact the Minnesota Department of Revenue at www.taxes.state.mn.us.
Legal Name
MN Tax ID or if none, Social Security
DBA (if different)
Mailing Address (if different):
Physical Street Address (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
Workers' Compensation:
Do you have any paid or otherwise compensated employees in Minnesota?
Yes
No If yes, complete the following information:
Insurance Company Name:
Effective Date:
Expiration Date:
Policy #:
You must provide acceptable evidence of compliance with the Workers' Compensation Insurance Law (MS Sec 176.182). If you are self-insured, attach a copy of the exemption
order from the Commissioner of Commerce authorizing self-insurance. For questions, contact the Minnesota Department of Labor and Industry at www.doli.state.mn.us.
Type of Warehouse:
Wood
Steel
Concrete
Other:
Equipment in the Warehouse:
Types of goods, wares, or merchandise intended to be stored:
Do you store:
Food
Fertilizer
Chemicals
Household Goods
(Attach additional sheets if necessary)
Licensed Locations:
License Number
License Fee:
County
Sq. Footage
Address
(for office use only)
600508(3100)
City/Zip
$
$
$
Bond Requirements:
If you store household goods, a General Merchandise Storage Bond in the
amount of at least $10,000 (per city) must be issued and a tariff must be filed.
License Fee
If you do NOT store household goods, $50,000 warehouseman's legal
Building Sq. Footage
Fee
liability insurance may be filed in place of the General Merchanside Storage
Less than 5,000
$110
If you store household goods, you must attach a copy of your current tariff
5,001 to 10,000
$220
showing rates and charges assessed before your license will be granted.
10,0001 to 20,000
$330
20,001 to 100,000
$440
Return this form with your check made payable to:
MINNESOTA DEPARTMENT OF AGRICULTURE
100,001 to 200,000
$550
Attn: Cashier
Over 200,000
$660
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable and fees are not refundable.
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651/201-6000. TTY users can
call the Minnesota Relay Service at 711 or 1-800-627-3529. The MDA is an equal opportunity employer and provider.
AG-00812 (01/11)
Page 1 of 1