M OR TU A RY S CI EN C E PR O GR AM
P.O. Box 64882, St. Paul, MN 55164-0882
Telephone: (651) 201-3829
Fax: (651) 201-3839
Email: [email protected]
Application for License to Operate a Funeral Establishment
The undersigned hereby submits this application to operate a funeral establishment subject to the provisions of Minnesota Statutes, section
149A.50 and 149A.65. Include an application fee of $425 payable to: Commissioner of Finance.
ESTABLISHMENT INFORMATION
Name of Establishment
Establishment License Number (MDH use only)
Mailing Address
City
Establishment Address ☐ Same as mailing address.
City
County
State
Zip Code
State
Zip Code
Email Address
Phone Number
Fax Number
Is there a prep room at this location?
If yes, what date and location was this established?
Type of Business (check one):
☐ Individual/Sole Proprietorship
☐ Partnership
Email
☐ No
☐ Yes
☐ Private/LLC Corporation
Federal IRS Tax I. D.
☐ Public Corporation
☐ Cooperative
MN Tax I.D.
Name of Owner(s)/Percentage of owners
Is this establishment a corporation?
If yes, answer the rest of this section’s questions.
Name of Corporation
Name of President
☐ No
☐ Yes
Place and Date of Incorporation
Corporation Address ☐ Same as business address above.
City
State
Zip Code
Name of Licensed Morticians and Mortician’s License Number Working at this Establishment
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 or, if not available, proof of zoning from city ordinance.
To obtain this information in a different format, call: 651-201-3829. Printed on recycled paper.
Document1
REV 8/5/2016