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(Name of individual, partnership, corporation, LLC)
(Contact person phone number)
(Contact person email)
Provide name of at least one supervisory employee with a current Certified Food Manager Certificate issued
by the Minnesota Department of Health. Attach additional sheets for additional certified staff.
Provide liability insurance certificate. See Insurance Requirements attached.
All public pool owners must certify all outlets except for unblockable drains are equipped with covers that
have been stamped by the manufacturer that they are in compliance with ASME/ANSI standards; and all covers
and grates, including mounting rings, have been inspected to ensure that they have been properly installed
and are not broken or loose.
Please do not provide the name of the insurance agent.
This field is not part of the form submission.
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