Minnesota > Statewide > Alcohol And Gambling Enforcement Division
Application For Consumption And Display Permit PS9007 - Minnesota
| Application For Consumption And Display Permit Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide . |
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Print Form 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 TDD651-282-6555 NOTE: ALL CLUB 'ON-SALE' INTOXICATING LIQUOR LICENSEES ARE EXEMPT FROM APPLYING. APPLICATION FOR CONSUMPTION AND DISPLAY (Set Up) PERMIT PEMIT FEE $250 (Permits expire March 31st of each year) Workers Comp. Ins. Co. Policy No. Licensee's MN Sales & Use Tax ID # Licensee's Federal Tax ID # Applicants Full Name (Business, Partnership, LLC, Corporation) Amount Received Dates of Coverage To apply for MN Tax ID# 651-296-6181 A $30.00 service charge will be added to all dishonored checks. You may also be subjected civil penalty of $100 or 100% of the value of the check, whichever is greater, plus interest and attorney fees. DOB SS# Trade Name or DBA Business Street Address or Box Number County Business Phone City State Zip Code Permit Type Private Club Public Business Type of Business (Restaurant, Dance Hall, etc.) Full Name of Business or Club Manager DOB Address of Manager Name of Building Owner Address of Owner Are the club or business Is there a current 3.2 Is application If transfer, former license and business trade name Yes Yes premises separate from any beer license to this Original Transfer No business at this location? No other business establishment? If a partnership, state the name and address of each partner. If a corporation, state the name and address of each officer. If a club, state the name and address of each officer or director. Full Name DOB SS# Address Full Name DOB SS# Address Full Name DOB SS# Address For a Private club. A club must attach a copy of the constitution and bylaws of the club and current list of members. Date club organized Number of members Amount of dues Is club owned or rented? Length of time club at present location Membership requirements Does club store liquor for members? Yes No Has applicant; if partnership, any partner; if corporation, any officer or director; if club, any club officer or director, ever had a license under the Minnesota Liquor Control Act revoked or suspended or been convicted for any violation of State laws or local ordinances; if so, give date and details. I hereby certify that the answers are true of my own knowledge and understand that the giving of false information or the failure to give pertinent information constitutes cause for revocation of this permit. THIS PERMIT DOES NOT ALLOW THE SALE OF INTOXICATING LIQUOR. Permittee Signature (Signature certifies all above information to be correct and permit has been approved by city/county.) Date City/County Auditor Signature (Signature certifies all above information to be correct and permit has been approved by city/county.) Date American LegalNet, Inc. www.FormsWorkFlow.com
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