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E9 MiniiMOM 0«p«mn«nt of Health <br />Environmonial Fiaid Strvicot <br />717 SE Oolawaro Si.. P O. Boi 9441 <br />Minnaaoolia, Minneaota S5440 <br />612'623-S33S •t <br />PRIMARY UCENSE: <br />(first licansa issuad to Park or Camp) <br />ANNUAL UCENSE Yaar Round (over 6 months): <br />— Saasonal (6 months or lass): <br />Ucatfon for Liconso to Opointt a <br />MSiufbeturad Homo^Park and/or <br />a^onajXampiiy Area <br />S7S.OO for aach SO sites or fraction tharaof <br />$15.00 for aach 10 sites or fraction thereof <br />Maximum of $450.00 <br />S11.25 for aach 10 sites or fraction tharaof <br />Maximum of $337.50 <br />^ SEE REVERSE SIDE FOR FEE SCHEDULE. COMPLETE WORKER'S COMPENSATION SECTION <br />^ ADO $10.00 LATE PAYMENT FEE IF APPLYING AFTER JANUARY IS FOR ANNUAL UCENSE OR 15 DAYS AFTER OPENIf <br />FOR SEASONAL OPERATION <br />^ MAKE CHECK PAYABLE TO: Minnesota State Treasurer <br />u NEW UCENSE INsw Sarss muu snsen lagsl CMcnsMn of sits, indtidt ail prapany ipr prosam or fuiura waa.)• <br />V RENEWAL C OWNERSHIP CHANGE <br />nrawous Oporetor Oaia ^rchasad <br />Last lleonaa na.wee iisuod for the followino ouantitv of: <br />Namo of Ucansoa Iparaon. Rrm or corporMioiU <br />Bid <br />Taiapnona <br />) <br />MaiHne Addrska lindudo tip cedol <br />Pd), fiox S<!?€: )c c e isl c Kl'/ In • SS is if <br />Part or Camp Trade Nemo <br />1^1 JT% la ^ A I'f'h fnv~tx u i C a uJi f . <br />A t <br />1 lube 'h? M <br />Coumy M U e* f' 1 H TownaHip d) V O w\ c Pott Ohica ir€ f*\ St e%' <br />^MtiMTiHia Of Corporttion — liM Offleors: <br />UL'i's d.-t f <br />av-T <br />400WCSS ' <br />I2IOO SS.Hr <br />'/If pis. <br />Operation: Q Year Round Saasonal (Mat opening data and months of operation): fTfsty IS , 5^ tuent'Ky <br />No. of Sites: <br />No. of Sites Occupied: <br />. Mobile Home Sites _INoio: OsesnSswe ihas are t <br />, Mobile Home Sltss . <br />ohotx M««sr csAnseMiA«.i <br />. Oepandent Camp Sitae <br />. Independent Camp Sites <br />. Independent Camp Sites <br />.Number of Fixtures m Central Building if provided:TOILET SEATS SHOWERS URINALS WASHBASINS <br />Is Swimming Pool provided? J yes no If Primitive Campground list number of prtvles; <br />Mon:///A <br />Women:a./O Ji <br />Water Supply: <br />Sewage System: <br />C municipal <br />□ municipal <br />^ private <br />private <br />No. of ahas with individual water '«ook<upe: <br />No. of sites with individual sewer hook-ups: <br />You must submit plans in triplicate for new construction or alteration. Ucense cannot be renewed without this department's pri< <br />approval for additional sites. You must submit a copy of an approval permit from the municipaliiy or county in which the par) c <br />camp Is located or a statement from that municipality or county that no permit is required. No license will be issued until e <br />requirements have been met. <br />Foe <br />Late Psyment Pee <br />TOTAL Ha-01IB3Ot <br />licsnsss's Signsiurs