Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division 444 Cedar Street, Suite 222, St. Paul, MN 55101 651-201-7500 Fax 651-297-5259 TTY 651-282-6555 APPLICATION FOR COUNTY/CITY ON-SALE WINE LICENSE (Not to exceed 14% of alcohol by volume) Print Form EVERY QUESTION MUST BE ANSWERED. If a corporation, an officer shall execute this application. If a partnership, LLC, a partner shall execute this application. To apply for MN sales Tax # call 651-296-6181 Workers compensation insurance company name Licensee's MN sales and Use Tax ID # Applicants Name (Business, Partnerships, Corporation Business Address City Is this application If a transfer, give name of former owner New or a Transfer Partner/Officer Name and title Partner/Officer Name and title Partner/Officer Name and title Partner/Officer Name and title Address Address Address Address CORPORATIONS Policy Number Licensee's Federal Tax ID # Trade Name or DBA Business Phone County Applicant's Home Phone State License Period From DOB DOB DOB DOB Zip Code To SSN SSN SSN SSN 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. Is corporation authorized to do business in Minnesota? Yes No If a subsidiary of another corporation, give name and address of parent corporation BUILDING AND RESTAURANT Date of incorporation State of incorporation Certificate Number Name of building owner Owner's address Are property taxes delinquent Has the building owner any connection, direct Restaurant seating capacity Hours food will be available or indirect with the applicant? Yes No Yes No Number of restaurant employees Number of months per year restaurant is open Will food service be the principal business? 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 No Has the applicant or associates been granted an on-sale malt liquor (3.2) and/or a "set-up" license in conjunction with this wine license? No 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. No During the past license year, has a summons been issued under the liquor civil liability (Dram Shop)(M.S. 340A.802). If Yes, attach copy of the summons. No Has applicant, partners, officers or employees ever had any liquor law violations in Minnesota or elsewhere. If so, give names, dates, violations and final outcome details. Yes Yes Yes Yes Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Yes No Does any person other than the applicants, have any right, title or interest in the furniture, fixtures or equipment in the licensed premises? If yes, give names and details. No Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? If yes, give name and address of establishment. Yes I CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS AND THAT THE ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature of Applicant Date The licensee must have one of the following: 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. A surety bond from a surety company with minimum coverage as specified above in. A certificate from the state treasurer that the licensee has deposited with the state, trust funds having a market 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 REPORT BY POLICE OR SHERIFF'S DEPARTMENT Date 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 IMPORTANT NOTICE Date 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 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. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com