Form AG00876 "Application for Wholesale Produce Dealer" - Minnesota

What Is Form AG00876?

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 April 24, 2018;
  • 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 fillable version of Form AG00876 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG00876 "Application for Wholesale Produce Dealer" - Minnesota

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625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Plant Protection Division, Phone: 651-201-6620
ENTITY ID:
Minn. Stat. 27.03(1)
20
New Application for Wholesale Produce Dealer
License Period July 1 to June 30
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.
ESTABLISHMENT INFORMATION
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:
City:
State:
Zip:
Company Telephone:
Cooperative - If at least 75% of the business is with member or stockholder patrons, you are not considered a Wholesale Produce Dealer and
you do not need to be licensed. However, if less than 75%, you are defined as a Wholesale Produce Dealer and need to file this application.
1
Please complete your license application form on the reverse side of this form first. Total amount
of produce (fruit, vegetables, milk, eggs, and poultry) purchased or contracted from Minnesota
$
farmers and other wholesale produce dealers during the previous 12 months. If you have made no
purchases in the past year, enter zero.
2
Multiply amount in number 1 by .00045. Enter this amount or $1,925, whichever is less.
$
3
$75.00 application fee.
$
4
Add lines 2 and 3. This is your license fee.
600378(3100)
$
5
If the fees are mailed after July 1, you must pay a penalty of an additional 10% of Line 4 for each
600378(3510)
$
month the fee is late.
6
A certified copy of the license must be posted at all branch locations where produce is purchased.
Number of certified copies needed ______ x $20.00 =
600378(3110)
$
[Attach a list of locations and branch managers.]
7
Persons soliciting produce on behalf of the licensee are required to carry a Produce Buyer’s
Identification Card. Number of identification cards needed ________ x $5.00 =
600380(3190)
$
[Attach a list of buyers, agents, etc.]
8
Trucks used to purchase or solicit produce are required to display a sticker identifying them as a
600381(3190)
$
licensee. Number of truck stickers needed _______ x $10.00 =
TOTAL FEES DUE (Add lines 4-8) $
Return this form with your check made payable to:
Note:
Minnesota Department of Agriculture
Licenses are not transferable and fees are not refundable.
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
I hereby certify that the information contained in and submitted with this form is true and correct.
For Official Use Only
Signature:
Date:
Name (Please Print):
Title:
Contact Telephone:
Fax Number:
E-mail Address:
PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM 
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG00876
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
4/24/18 Page 1 of 2
625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Plant Protection Division, Phone: 651-201-6620
ENTITY ID:
Minn. Stat. 27.03(1)
20
New Application for Wholesale Produce Dealer
License Period July 1 to June 30
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.
ESTABLISHMENT INFORMATION
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:
City:
State:
Zip:
Company Telephone:
Cooperative - If at least 75% of the business is with member or stockholder patrons, you are not considered a Wholesale Produce Dealer and
you do not need to be licensed. However, if less than 75%, you are defined as a Wholesale Produce Dealer and need to file this application.
1
Please complete your license application form on the reverse side of this form first. Total amount
of produce (fruit, vegetables, milk, eggs, and poultry) purchased or contracted from Minnesota
$
farmers and other wholesale produce dealers during the previous 12 months. If you have made no
purchases in the past year, enter zero.
2
Multiply amount in number 1 by .00045. Enter this amount or $1,925, whichever is less.
$
3
$75.00 application fee.
$
4
Add lines 2 and 3. This is your license fee.
600378(3100)
$
5
If the fees are mailed after July 1, you must pay a penalty of an additional 10% of Line 4 for each
600378(3510)
$
month the fee is late.
6
A certified copy of the license must be posted at all branch locations where produce is purchased.
Number of certified copies needed ______ x $20.00 =
600378(3110)
$
[Attach a list of locations and branch managers.]
7
Persons soliciting produce on behalf of the licensee are required to carry a Produce Buyer’s
Identification Card. Number of identification cards needed ________ x $5.00 =
600380(3190)
$
[Attach a list of buyers, agents, etc.]
8
Trucks used to purchase or solicit produce are required to display a sticker identifying them as a
600381(3190)
$
licensee. Number of truck stickers needed _______ x $10.00 =
TOTAL FEES DUE (Add lines 4-8) $
Return this form with your check made payable to:
Note:
Minnesota Department of Agriculture
Licenses are not transferable and fees are not refundable.
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
I hereby certify that the information contained in and submitted with this form is true and correct.
For Official Use Only
Signature:
Date:
Name (Please Print):
Title:
Contact Telephone:
Fax Number:
E-mail Address:
PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM 
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG00876
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
4/24/18 Page 1 of 2
New Application for Wholesale Produce Dealer
License Number:
The following produce is subject to the Minnesota Wholesale Produce Dealer Act, Minnesota Stat. Section 27.01(2).
What produce do you purchase or contract for?
Milk
Eggs
Poultry
Potatoes
Vegetables and/or fruit
Wholesale Produce Dealer - The following businesses need to be licensed as Wholesale Produce Dealers if they are purchasing or contracting
produce subject to MN Statute 27.01. Which one best describes your business?
Wholesaler
Cannery
Food Manufacturer
Food Processor
Broker
Retailer
1
If you are a retailer, do you purchase from Minnesota farmers or farm cooperatives?
Yes
No
2
If you are a broker, do you collect a commission or fee?
Yes
No
In the following questions, the amount purchased refers to all purchases paid by check or paid for beyond 24 hours after the produce was
received. The amount purchased or contracted for from Minnesota farmers and other Minnesota Dealers for above produce during the
previous 12 months, if any:
Previous 12 months total $
Highest monthly amount $
Estimated amount for the next 12 months $
Type of Business
Sole Proprietorship
Corporation/LLC
Partnership
Cooperative
If corporation, give the state of incorporation:
Names and Titles of Individuals/Officers Operating Business:
Pursuant to Minnesota Statutes Section 18J.05 Subd 6, all persons obtaining a license under Minnesota Statutes chapter 27 must appoint
the Commissioner of Agriculture as the agent upon whom all legal process may be served. I understand that service of process upon the
Commissioner is deemed to be service upon my operation.
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG00876
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
4/24/18 Page 2 of 2
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