DIRECTIONS FOR COMPLETING AND RETURNING
THE MINNESOTA WIC PROGRAM VENDOR APPLICATION FORM
APPLICATION TYPE
Put a check mark next to why your store is submitting this application.
*If your store is a current WIC vendor applying for reauthorization, please also write in your stamp number.
*If your store is applying for authorization under a new ownership, please record the date of the sale, and the name of the store under the previous ownership.
STORE IDENTIFICATION
*Fill in the name of your store that is most familiar to your customers. For example: Tom and Mary's Corner Store, Lyndale Grocery, Walden's Foods.
*List your store’s telephone number and fax number (if you have one)
*Physical address: List the store’s physical address, including county, and provide simple directions to the store from main highways/intersections.
*Mailing address: List the mailing address to which we should send mail, if it is different from the store’s physical address. If your mail is sent to a PO Box or rural route, list that.
TYPE OF STORE
Check the classification which best describes your store.
*Neighborhood or Convenience Store -- These stores are generally small with a limited product line and have 1 or 2 cash registers.
*Chain-Owned Supermarket -- These stores are larger than convenience stores and have three (3) or more cash registers. The distinguishing feature of this type of store is that a number of stores are owned by the same firm.
*Independently-Owned Supermarket -- These stores are larger than convenience stores and have three (3) or more cash registers. These stores are independently owned and operated.
Also indicate if a pharmacy is available in your store.
STORE CONTACT INFORMATION
*List the name of the Store Manager
*List the name, title and email address of the WIC contact person for the store. The person who is responsible for WIC at the store level, or who trains cashiers concerning WIC.
STORE HOURS
*Check whether or not the store is open at least 40 hours per week (which is a WIC Program Requirement)
*Indicate if your store is open 24 hours a day, and if it is not, indicate what time your store opens and closes each day of the week.
STORE INFORMATION
*Enter the Federal Tax ID Number. If the store is owned by a sole owner, this may be the owner’s Social Security Number.
*Enter the store’s State Sales Tax Number.
*Enter the estimated square footage of the store.
*Enter the number of cash registers/cash register lanes that are in the store.
*Enter the store’s annual food sales. If this is a new store, or a store that is changing ownership, enter the estimated amount.
*Indicate whether your store’s WIC sales will (or do) exceed 50% of the store’s total food sales (State Rules prohibit this).
*Indicate whether your store will (or does) provide receipts to WIC customers (this is required by State Rules).
*Indicate whether your store’s cash register(s) has/have scanners.
*Indicate whether your store’s cash register(s) has/have scanners capable of detecting which foods are WIC-allowed.
*Record the address where the store’s WIC food invoices and purchase records will be stored. State Rules require that these records be available for immediate review by WIC staff during business hours.
WHOLESALER INFORMATION
*Enter the name, address and telephone number of your primary grocery supplier or wholesaler.
*Enter the name, address and telephone number of your primary dairy supplier or wholesaler.
*Enter the name, address, and telephone number of your primary source for WIC-allowed infant formulas.
FOOD STAMP AUTHORIZATION INFORMATION
*Enter your full Food Stamp Authorization number, OR if your authorization is pending, OR if your store is not Food Stamp authorized and does not intend to become so. (Note: State Rules require that WIC vendors be authorized to accept food stamps).
QUESTIONS REGARDING HISTORY OF SANCTIONS
*Answer the questions as appropriate
We need to know your store's prices for WIC-allowed foods. We also need to know if you have the minimum amount and variety of stock required to be on the WIC Program. Please complete each section on pages 3-7. If you do not meet the WIC Program's pricing requirements, we will notify you so that you can correct the problem before the store is visited.
*Enter only the prices of WIC-approved foods. A WIC approved foods list is included with this application packet.
*If you stock only one brand of a product, take that price.
*If you stock two or more brands of a product, find the highest price of the product and use that price.
*If you do not stock a specific type or brand of product, leave the space blank.
Please complete one subsection of the Ownership Documentation section.
*Complete Subsection A (on page 8) if the store’s owner is a sole proprietor (one person).
*Complete Subsection B (on page 8) if the store is owned by a partnership or two or more people.
*Complete Subsection C (pages 9 and 10) if your store is owned by a corporation, a tribal agency or a cooperative. You must list all Officers. If the store is owned by a corporation be sure to also complete the Shareholder information on page 10.
Please include with your application a copy of either your store’s Minnesota Retail Food Handler’s License or the City or CountyGrocer’s License. Examples of these licenses can be found on page 11.
It is important that the store Owner, Partner, or Corporate Officer reads the Statement of Vendor Compliance and Ownership Certification on page 12 so that he/she/they clearly understand the terms of this application. If all is understood and agreed to, the Owner, Partner or Corporate Officer should sign at the bottom of this page, and complete the Printed name, Title and Date information.
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If you have questions while completing this form, call (651) 215-9694 or (651) 201-4415, or toll free at
1-800-657-3942, extension (651) 201-4417
Return the entire completed form, along with a copy of the store’s license, to:
Mark Peine
Minnesota Department of Health - WIC Program
P.O. Box 64882
St. Paul, Minnesota55164-0882