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Application For Micro Distillers License - Minnesota

Application For Micro Distillers License Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide .
 Fillable pdf Last Modified 1/4/2014
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Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street/Suite 222, St. Paul, MN 55101-5133 (651) 201-7507 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR MICRO DISTILLERS LICENSE LICENSE EXPIRATION DATE _____________ LICENSE # _________________________ DATE APPROVED____________ WORKERS COMP. INS. CO. __________________POLICY # ________________________ POLICY PERIOD________________ MINNESOTA TAX ID # Licensee's name (business, partnership, LLC, corporation) Business address City Warehouse Date of incorporation State of incorporation Certificate number FEDERAL TAX ID # DOB Social Security # DBA or trade name Phone State City Zip Code State Fax # License period From To is corporation authorized to do business in Minnesota? Yes No Indicate type: Submit a certified check and a surety bond in the amount specified. Manufacturer of Distilled Spirits of 20,000 to 40,000 proof gallons Manufacturer of Distilled Spirits of fewer than 20,000 proof gallons Fee - $2,000.00 plus $150.00 OET Surcharge Total Due $2,150.00 Fee - $1,000.00 plus $100.00 OET Surcharge Total Due $1,100.00 Bond - $3,000.00 Bond - $2,000.00 Give full name, address, DOB, Social Security # and title of the applicant and for all partners or officers and principal stockholders for corporations. State below the partnership interest of each partner and for a corporation the percentage of stock held by each officer. Name Address Name DOB City DOB Social Security # Title Social Security # Title State Percent stock of partnership interest Zip Code Percent stock of partnership interest Address Name Address City DOB City Social Security # Title State Zip Code Percent stock of partnership interest State Zip Code MAKE CHECK PAYABLE TO: DIRECTOR ALCOHOL AND GAMBLING ENFORCEMNT AMOUNT RECEIVED A $30.00 service charges 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. MS 604.113 PS 09101D (05/11) American LegalNet, Inc. www.FormsWorkFlow.com Distiller: State number of proof gallons to be produced per year.____________________________________ Describe the storage and warehousing facilities and/or the bottling and production capacity and the number of floors used. ________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ List Federal Basic Permit numbers and their effective dates: Permit type _______________________ Permit # __________________________Effective date ___________ Permit type _______________________ Permit # __________________________Effective date ___________ It is the responsibility of the applicant upon license approval to insure purity of product manufactured for human consumption. Periodic batch tests should be conducted to insure purity of product. Records of test results are to be kept at the licensed premises available for inspection by agents of the Alcohol & Gambling Enforcement Division for a minimum of two (2) years after the date of testing. State method used to determine product composition, alcohol content and purity: In House Lab, Contract Lab, Other: __________________________________________________________________________________________ _______________________________________________________________________________________ State whether applicant or any person named herein own any stock or have any financial interest in any brewery, manufacturer, wholesale distributor or retail alcoholic beverage establishment in this State or any other State. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ State whether applicant, partners, or officers were ever indicted or convicted for any violation of the Minnesota Liquor Control Act or a felony in this State or any other State or under federal laws. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Manufacturers: Names of Minnesota Wholesalers. (Attach additional sheet if needed) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ All statements and documents submitted with this application shall become a permanent part of the record. The Liquor Control Director has the right to reject or revoke any license or license application containing a false statement. I certify that the information submitted is true and correct to the best of my knowledge. Print full name of applicant and title Signature of applicant Date NOTE If this application is for a new partnership, submit a certified copy of the partnership agreement. For a new corporation, include a certified copy of the articles and by-laws. If this application is for a license renewal, submit a copy of any amendment made to the partnership agreement or the articles of incorporation and by-laws since the last license was issued. American LegalNet, Inc. www.FormsWorkFlow.com
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