ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar St., Suite 222, St. Paul, MN 55101-5133 Fax (651) 297-5259 (651) 201-7507 TTY (651) 282-6555 WWW.DPS.STATE.MN.US APPLICATION FOR COUNTY ON-SALE INTOXICATING LIQUOR LICENSE No license will be approved or released until MN Liquor Control receives the $20 Retailer ID Card fee. Workers Compensation Insurance Company Policy # ___________________________________ LICENSEE'S SALES & USE TAX ID # To apply for MN sales tax number call 651-296-6181 LICENSEE’S FEDERAL TAX ID # ____________________________ Applicant's name (Business, partnership, LLC, Corporation) DOB Social Security # License address DBA or trade name Business phone City County State Applicant's home phone Zip Code License period From To Give name, residence, DOB, Social Security #, title and age for all partners, or the officers and directors of a partnership or corporation. and the percent of stock held by each officer if applicable. Name Social Security # Title DOB Percent stock or partnership interest Address City Name Social Security # Address State Title DOB Percent stock or partnership interest City Name Social Security # Address State Title DOB Percent stock or partnership interest City Date of Incorporation State of incorporation Purpose of corporation Certificate Number State Is corporation authorized to do business in Minnesota? Yes No If a subsidiary of another corporation, give name 1. Describe premises to be licensed (location, facilities). Floor establishment is located on Seating capacity Number of months per year establishment will be open 2. 3. 4. 5. 6. Hours food will be available Number of people restaurant employs Name of manager If this restaurant is in conjunction with any other business (resort, etc.), describe the business. Name the nearest municipality in which On Sale licenses are issued. Has applicant, partners, officers or employees ever had any Felony Convictions or Liquor Law violations in Minnesota or elsewhere, including State Liquor Control Penalties? Yes No If yes, give date, charges and final outcome. Is the applicant or any of the associates in this application a member of the County Board in which the license will be issued? Yes No If yes, in what capacity? (If the applicant for this license or any of the associates is the spouse of a member of the governing body or where a family relationship exists, the member shall not vote on this application.) Yes No Have the applicants any interest, directly or indirectly, in any other liquor establishment in the county or any city in the county issuing this license. If yes, give the name and address of the establishment. American LegalNet, Inc. www.FormsWorkFlow.com Yes No 7. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. If yes, attach a copy of the summons. Yes No 8. Will you serve liquor on Sunday? Amount of Sunday License Fee. Yes No 9. Is this establishment located in an organized township? If so, attach township approval. Yes No 10. Has a restaurant license been issued by the state or local health department for this establishment? I certify that I have read the above questions and that the answers are true and correct to the best of my own knowledge. Name of applicant (please print or type) Applicant's signature Date _________________________________________________________________________________________________________________ The Licensee must have one of the following: Check one A. or B. or C. 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. A certificate from the State Treasurer that the licensee has deposited with the State, Trust Funds having a market value of $10,000 $100,000 in cash or securities. REPORT BY COUNTY ATTORNEY I certify that to the best of my knowledge the applicants named above are eligible to be licensed. Signature County Attorney County Yes No If no, state reason Date REPORT BY SHERIFF I certify that to the best of my knowledge, the applicants named above have not been convicted within the last five years for any violations of State law or municipal ordinance relating to the sale of liquor, except as follows: Signature Sheriff County 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 attorneys fees. M S 604.113 (PS 9015-2009) American LegalNet, Inc. www.FormsWorkFlow.com