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 ON-SALE INTOXICATING LIQUOR LICENSE To apply for MN Sales tax number call 651-296-6181 Print Form No license will be approved or released until MN Alcohol and Gambling Enforcement receives the $20 retailer ID card fee. Workers compensation insurance company name Licensee's MN sales and Use Tax ID # Applicants Name (Business, Partnerships, Corporation Business Address City County State DOB SSN Policy Number Licensee's Federal Tax ID # Trade Name or DBA Applicant's Home Phone License Period From DOB DOB DOB DOB Certificate Number Business Phone Zip Code To SSN SSN SSN SSN Give information requested below 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, title, and percent ownership Name, title, and percent ownership Name, title, and percent ownership Name, title, and percent ownership Date of incorporation Purpose of corporation Describe the premises to be licensed Floor establishment is located on Address Address Address Address State of incorporation Is corporation authorized to do business in Minnesota? Yes No If a subsidiary of another corporation, give name Number of restaurant employees Seating capacity Name of manager Hours food will be available Number of months per year establishment will be open If the restaurant is in conjunction with another business (resort etc.), describe business Name the nearest municipality on sale licenses are issued. Yes No Has applicant, partners, officers or employees ever had any felony convictions or liquor law violations in Minnesota or elsewhere. If so, give names, dates, violations and final outcome details. 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 Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? If yes, give name and address of establishment. 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 Will you serve liquor on Sunday? Amount of Sunday license fee No Is this establishment located in an organized township? If so, attach township approval. No Has a restaurant license been issued by the state or local health department for this establishment? Yes Yes Yes Yes Yes Yes Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS AND THAT THE ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Name of applicant (please print or type) 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. 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