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 for License to Operate a Crematory
The undersigned hereby submits this application to operate a crematory subject to the provisions of Minnesota Statutes, section 149A.50 and
149A.65. Include an application fee of $425 payable to: Commissioner of Finance.
CREMATORY INFORMATION
Name of Crematory
Mailing Address
City
State
City
Establishment Address ☐ Same as mailing address.
County
Zip Code
State
Zip Code
Email Address
Phone Number
Fax Number
Email Address
Type of Business (check one):
☐ Individual/Sole Proprietorship
☐ Partnership
☐ Private/LLC Corporation
☐ Public Corporation
☐ Cooperative
Name of Owner(s) Percentage of Ownership:
Federal IRS Tax Number
Minnesota Tax I.D. Number (or Owner’s Social Security Number)
Is this crematory a corporation?
If yes, answer the rest of this section’s questions.
Place and Date of Incorporation
Name of Corporation
Corporation Address ☐ Same as mailing address above.
Name of President
City
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 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 05/27/2016