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 COUNTY/CITY ON-SALE WINE LICENSE (Not to exceed 14% of alcohol by volume) EVERY QUESTION MUST BE ANSWERED. If a corporation, an officer shall execute this application. If a partnership, LLC, a partner shall execute this application. Workers compensation insurance company. Name Policy # To apply for MN Sales Tax # call (651) 296-6181 LICENSEE'S MN SALES & USE TAX ID # LICENSEE’S FEDERAL TAX ID # Applicants Name (Business, Partnership, Corporation) Trade Name or DBA Business Address Business Phone ( ) Applicant's Home Phone ( ) City County State Zip Code License period From To Is this application New or a Transfer If a transfer, give name of former owner If a corporation, give name, title, address and date of birth of each officer. If a partnership, LLC, give name, address and date of birth of each partner. Partner/Officer Name and title Address Social Security # DOB Partner/Officer Name and Title Address Social Security # DOB Partner/Officer Name and Title Address Social Security # DOB Partner/Officer Name and Title Address Social Security # DOB CORPORATIONS Date of incorporation State of incorporation Certificate Number Is corporation authorized to do business in Minnesota? Yes No If a subsidiary of another corporation, give name and address of parent corporation Name of building owner BUILDING AND RESTAURANT Owner's address Are Property Taxes delinquent? Has the building owner any connection, direct or indirect, with the applicant? Yes No Restaurant seating capacity Hour’s food will be available No. of people restaurant employs Will food service be the principle business? Yes No No. of months per year restaurant will be open Yes No Describe the premises to be licensed If the restaurant is in conjunction with another business (resort etc.), describe business NO LICENSE WILL BE APPROVED OR RELEASED UNTIL THE $20 RETAILER ID CARD FEE IS RECEIVED BY AGED American LegalNet, Inc. www.FormsWorkFlow.com OTHER INFORMATION Yes No 1. Has the applicant or associates been granted an on-sale non-intoxicating malt beverage (3.2) and/or a "set-up" license in conjunction with this wine license? Yes No 2. Is the applicant or any of the associates in this application a member of the county board or the city council, which will issue this license? If yes, in what capacity? . (If the applicant is the spouse of a member of the governing body, or another family relationship exists, the member shall not vote on this application.) Yes No 3. During the past license year, has a summons been issued under the liquor civil liability (Dram Shop) (M.S. 340A.802). If yes, attach a copy of the summons. Yes No 4. Has applicant, partners, officers or em ployees ever had any liquor law violations in Minnesota or elsewhere. If so, give names, dates, violations and final outcome. __________________________________________________________________________________________ Yes No 5. Does any person other than the applicants, have any right, title or interest in the furniture, fixtures or equipm ent in the licensed premises? If yes, give names and details. _______________________________________________________________________________________________ Yes No 6. Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? If y es, give name and address of the establishment. I CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS A ND THAT THE ANSW ERS ARE TRUE AND CORRECT TO THE BEST OF MY OWN KNOWLEDGE Signature of Applicant The licensee must have one of the following: (Check one) A. 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. ATTACH "CERTIFICATE OF INSURANCE" TO THIS FORM. B. A Surety bond from a surety company with minimum coverage as specified above in A. C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a m arket value of $100,000 or $100,000 in cash or securities. IF LICENSE IS ISSUED BY THE COUNTY BOARD, REPORT OF COUNTY ATTORNEY Yes No I certify that to the best of my knowledge the applicants named above are eligible to be licensed. If no, state reason. Signature County Attorney County Date REPORT BY POLICE OR 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, Municipal or County Ordinances relating to Intoxicating Liquor, except as follows: ___________________ ________________________________________________________________________________________________________________ Signature Department and Title Date IMPORTANT NOTICE ALL RETAIL LIQUOR LICENSEES MUST REGISTER WITH THE ALCOHOL, TOBACCO TAX AND TRADE BUREAU. FOR INFORMATION CALL (513) 684-2979 OR 1-800-937-8864 NOTICE A $30.00 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100.00 or 100% of the value of the check, whichever is greater, plus interest and attorney fees. American LegalNet, Inc. www.FormsWorkFlow.com