[City of Shoreview] Mobile vendor permit

Mobile vendor application

Application type

Peddler (selling goods or services for immediate delivery)

Solicitor (selling goods or services for future delivery)

Mobile food unit (i.e. food or ice cream trucks)

Non-profit organization

Total Cost

Applicant information

Other names (maiden name, previous marriages, previous aliases)

Phone Number

Driver's license information

Driver's license number *

Issuing state *

Have you ever been charged with a misdemeanor, gross misdemeanor, or felony violation?

Yes

Please list the nature, date, and status of the offense.

Upload picture ID

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Last five cities applicant has worked

Business information

Business name

Phone Number

Goods or services to be sold

Requested permit dates

Vehicle information

Make *

Model *

Color *

License plate information

Number *

Issuing state *

Non-profit organization information

Non-profit name

Type of organization

Goods or services to be sold

Requested permit dates

Please upload proof of your non-profit status in the State of Minnesota

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Consent for the release of information

This consent is for the relase of information in accordance with MSA 13.05, subd. 4(d)

I authorize the Ramsey County Sheriff’s Office to release criminal history data, as defined by Minnesota Statute 13.87, subd. 1 and driver’s license and traffic record data to the Deputy Clerk for the City of Shoreview. I understand that some of this data may be classified as private data under Minnesota statutes and I hereby give my informed consent to the release of that private data by the Ramsey County Sheriff’s Office to the deputy cerk for the City of Shoreview. This consent for the release of data is for the purpose of obtaining a permit or license with the City of Shoreview. This information cannot be used for any other purposes. This authorization may be revoked in writing by me at any time and in no event will it be valid for more than one year from the date below.

Yes

Other names (maiden name, previous marriages, previous aliases)

Additional information

Sex *

Date of birth *

Driver's license number and issuing state *

By signing this application, I:

Swear that all statements by me on this form are true and complete to the best of my knowledge
Understand that false statements or omissions shall be sufficient cause for rejecting my license
Authorize the City of Shoreview to use this information to determine my suitability for obtaining a license.

PRIVACY NOTICE/TENNESSEN WARNING:
In connection with your request for a license, the City has asked that you provide information about yourself which may be classified as private, confidential, nonpublic, or protected nonpublic under the Minnesota Government Data Practices Act. This means that this data is not ordinarily available to the general public. Accordingly, the City is required to inform you of the following:
1. The purpose and intended use of the information requested is to determine if you are eligible for a mobile vendor permit from the City of Shoreview.
2. The known consequences of supplying the requested information is that the information or further investigation could disclose information which could cause your application to be denied.
3. You are not legally obligated to supply the requested information. The known consequences of refusing to supply the requested information is that your request for a license cannot be processed.
4. A criminal charge, arrest, or conviction will not necessarily bar you from obtaining a license with the City, unless the conviction is related to the matter for which the license is sought, according to Minn Stat. 364.03. However, failure to reveal the requested criminal information will be considered falsification of the application and may be used as grounds for the denial of the application.
5. Other governmental agencies necessary to process your application are authorized by law to receive the information provided.
6. The city is required by law to furnish some of this information to the Department of Labor and Industry and the Minnesota Commissioner of Revenue.
The undersigned, by signing this notice, acknowledges that he/she has read and understood the contents of this notice and has received a copy of this notice.

My signature constitutes agreement of the Tennessen Warning and this entire application.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.