Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 (651) 201-7507 FAX (651)297-5259 TTY(651)282-6555 WWW.DPS.STATE..MN.US APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE No license will be approved or released until the $20 Retailer ID Card fee is received Workers compensation insurance company. Name ________________________________Policy # ___________________________ Licensee's MN Sales and Use Tax ID # ____________________________ To apply for a MN sales and use tax ID #, call (651) 296-6181 Licensee's Federal Tax ID #______________________________________________ If a corporation, an officer shall execute this application If a partnership, a partner shall execute this application. Licensee Name (Individual, Corporation, Partnership, LLC) License Location (Street Address & Block No.) City Name of Store Manager Social Security # License Period From County Business Phone Number To State Zip Code DOB (Individual Applicant) Trade Name or DBA Applicant's Home Phone # If a corporation or LLC state name, date of birth, Social Security # address, title, and shares held by each officer. If a partnership, state names, address and date of birth of each partner. Partner Officer (First, middle, last) Partner Officer (First, middle, last) Partner Officer (First, middle, last) Partner Officer (First, middle, last) DOB DOB DOB DOB SS# SS# SS# SS# Title Title Title Title Shares Shares Shares Shares Address, City, State, Zip Code Address, City, State, Zip Code Address, City, State, Zip Code Address, City, State, Zip Code 1. If a corporation, date of incorporation , state incorporated in , amount paid in capital . If a subsidiary of any other corporation, so state and give purpose of corporation . If incorporated under the laws of another state, is corporation authorized to do business in the state of Minnesota? Yes No Describe premises to which license applies; such as (first floor, second floor, basement, etc.) or if entire building, so state. Is establishment located near any state university, state hospital, training school, reformatory or prison? approximate distance. Yes No If yes state 2. 3. 4. Name and address of building owner: Has owner of building any connection, directly or indirectly, with applicant? Yes No Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license is to be issued? Yes No If yes, in what capacity? 5. 6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license is applied and if so, give name and details. ______________________________________________________________________ 7. Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota? Yes No If yes, give name and address of establishment. ________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 8. 9. 10. 11. 12. 13. 14. Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business establishment? Yes No State whether applicant has or will be granted, an On sale Liquor License in conjunction with this Off Sale Liquor License and for the same premises. Yes No Will be granted State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor License. Yes No Will be granted If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. _______________ State Number of Employees _______________ If this license is being issued by a County Board, has a public hearing been held as per MN Statute 340A.405 sub2(d)?__________ If this license is being issued by a County Board, is it located in an organized township? If so, attach township approval. 1. State whether applicant or any of the associates in this application, have ever had an application for a liquor license rejected by any municipality or state authority; if so, give dates and details. _______________________________________________________ 2. Has the applicant or any of the associates in this application, during the five years immediately preceding this application ever had a license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so, give dates and details. __________________________________________________________________________________________________ Has applicant, partners, officers, or employees ever had any liquor law violations or felony convictions in Minnesota or elsewhere, including State Liquor Control penalties? Yes No If yes, give dates, charges and final outcome. 3. 4. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. Yes No If yes, attach a copy of the summons. (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) This licensee must have one of the following: Check one A. or Liquor Liability Insurance (Dram Shop) - $50,000 per person, $100,000 more than one person; $10,000 property destruction; $50,000 and $100.000 for loss of means of support. A surety bond from a surety company with minimum coverage as specified in A. A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having market value of $100,000 or $100,000 in cash or securities. Signature of Applicant Date B. or C. I certify that I have read the above questions and that the answers are true and correct of my own knowledge. Print name of applicant & title REPORT BY POLICE\SHERIFF'S DEPARTMENT This is to certify that the applicant and the associates named herein have not been convicted within the past five years for any violation of laws of the State of Minnesota or municipal ordinances relating to intoxicating liquor except as follows: Police/Sheriff's Department Title Signature PS 9136-(2006) County Attorney's Signature IMPORTANT NOTICE All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, and Firearms. For information call (651)726-0220 American LegalNet, Inc. www.FormsWorkflow.com