MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Application to Renew License to Operate a Crematory
The undersigned hereby submits an application to operate a crematory subject to the provisions of Minnesota Statutes, section 149A.52 and rules
adopted thereunder. Include an application fee of $425 payable to: Commissioner of Finance. If postmarked after June 30th, include a late fee of
$100.
CREMATORY INFORMATION
Name of Crematory
Establishment License Number
Mailing Address
City
Establishment Address ☐ Same as business address.
Phone Number
City
County
Fax Number
State
Zip Code
State
Zip Code
Email address
Type of Business (check one):
☐ Individual/Sole Proprietorship
☐ Partnership
Name of Corporation
☐ Private/LLC Corporation
☐ Public Corporation
☐ Cooperative
Name of President
Name of owner(s) and percentage of ownership:
Is this crematory a corporation?
If yes, answer the rest of this section’s questions.
Federal IRS Tax Number
Place and Date of Incorporation
Corporation Address ☐ Same as business address above.
City
Minnesota Tax I.D. Number (or Owner’s Social Security Number)
State
Zip Code
Name of Licensed Morticians and Mortician’s License Number:
INSURANCE INFORMATION
All applicants must provide proof of liability insurance coverage.
Name of Insurance Provider
Insurance Policy Number
Insurance Agent’s Name
Insurance Agent’s Phone Number
I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that misstatement of facts may result in denial of this
application.
Printed Name of Applicant
Signature of Applicant
Date
Include copies of the following documents with this application: 1) Liability insurance coverage; 2) Filing with the Minnesota Secretary of State; and
3) Occupancy permit.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1
REV 04/01/2016