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Application For Small Brewer Off Sale Intoxicating Liquor License - Minnesota

Application For Small Brewer Off Sale Intoxicating Liquor License Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide .
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Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar Street, Suite 222, St. Paul, MN 55101 (651) 201-7500 TDD (651) 282-6555 FAX (651) 297-5259 APPLICATION FOR SMALL BREWER OFF SALE INTOXICATING LIQUOR LICENSE Workers Comp. Ins, Co. Minnesota Tax ID Number Licensee's Name (business, partnership, LLC, corporation) Business address City Name of Store Manager State DOB Policy Number Federal Tax ID Number Social Security Number DBA or Trade Name Fax Number License Period From Phone Number Zip Code Phone Number To DOB (Individual Applicant) If a corporation or LLC state name, date of birth, Social Security Number address, title, and share held by each officer. If a partnership, state names, address and date of birth of each partner. DOB SS# Title Shares Business address Partner Officer (First, middle, last) Partner Officer (First, middle, last) Partner Officer (First, middle, last) Partner Officer (First, middle, last) DOB DOB DOB SS# SS# SS# Title Title Title Shares Shares Shares Business address Business address Business address 1. If a corporation, date of incorporation , amount paid in capital and give purpose of corporation authorized to do business in the state of Minnesota? Yes No , state incorporate in . If a subsidiary of any other corporation, so state . If incorporated under the laws of another state, is corporation 2. Describe premises to which license applies; such as (first floor, second floor, basement, etc.) or if entire building, so state. Yes No 3. Is establishment located near any state university, state hospital, training school, reformatory or prison? if yes state approximate distance. 4. Name and address of building owner: Yes No Has owner of building any connection, directly or indirectly, with applicant? Yes No 5. Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license is to be issued? If yes, in what capacity? 6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license is applied and if so, give name and details. 7. Have applicants any interest whatsover, directly or indirectly, in any other liquor establishment in the state of Minnesota? Yes No If yes, give name and address of establishment. American LegalNet, Inc. www.FormsWorkFlow.com 8. Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business Yes No establishment? 9. State whether applicant has or will be granted, an On sale Liquor License in conjunction with this Off Sale Liquor License and for the No Yes Will be Granted same premises. 10. State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor License. No Yes Will be Granted 11. If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. 12. State Number of Employees 13. If this license is being issued by a County Board, has a public hearing been held as per MN Statute 340A.405 sub2(d)? 14. If this license is being issued by a County Board, is it located in an organized township? If so, attach township approval. 1. State whether applicant or any of the associates in this application, have ever had an application for a liquor license rejected by any municipality or state authority; if so, give dates and details. 2. Has the applicant or any of the associates in this application, during the five years immediately preceding this application ever had a license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so, give dates and details. 3. Has applicant, partners, officers, or employees ever had any liquor law violations or felony convictions in Minnesota or elsewhere, Yes No including State Liquor penalties? If yes, give dates, charges and final outcome. 4. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. No Yes If yes, attach a copy of the summons. This licensee must have one of the following: Check one (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) 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. A surety bond from a surety company with minium coverage as specified in A. A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having market value of $100,000 or $100,000 in cash or securities. I certify that I have read the above questions and that the answers are true and correct of my own knowledge. Print name of applicant and title Signature of applicant Date REPORT BY POLICE\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 or municipal ordinances relating to intoxicating liquor except as follows: Police/Sheriff's Department Title Signature County Attorney's Signature IMPORTANT NOTICE All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, and Firearms. For information call (651) 726-0220 American LegalNet, Inc. www.FormsWorkFlow.com
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