Vending Form

Kandiyohi County Health And Human Services

2200 23^rd Street NE, Suite 1080

Willmar, MN 56201

320-231-7800

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2024 Vending Machine License Application

1. List all vending machines dispensing food items on the bottom of the form.

2. A vending machine inspection fee of $15.00 per machine is due for each machine located in

Kandiyohi County. Vending machines dispensing only gum balls, hard candy, unsorted

confections, bottled or canned soft drinks, or ice manufactured and packaged by

another are exempt from this inspection fee.

Note: Wrapped candy is not exempt from vending fee.

3. License application and fee is due by December 31st.

4. Make checks payable to: Kandiyohi County Health and Human Services

5. Number of machines X $15 per machine =

Establishment Information

Establishment Name:

Owner Name:

Establishment Address:

City: State:

Zip:

Telephone:

Workers Compensation Information:

Pursuant to Minnesota Statutes 176.182 & 270C.72, the following applicable information is required of each license applicant:

Minnesota Tax ID Number:

Federal Tax ID Number:

Worker's Comp Policy Number:

Name of Worker's Compensation Insurance Company:

Address:

Name of Location and/or Building	Street Address, City, and Zip	Number of Food Vending Machines	Type of Machine, e.g.: candy, soup, beverage, snack

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This is to certify that I am the individual who is the subject/business owner of the requested application.

This statement is to certify that all of the information in this application is true and correct and has been provided by the above named subject/business owner.

I certify that the information provided on this application is accurate and complete.

Online Application Completed

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