PS-9114 (11-89) --------------------------------------------------- MINNESOTA DEPARTMENT OF PUBLIC SAFETY LIQUOR CONTROL DIVISION 333 SIBLEY, ST. PAUL, MN 55101 PHONE (612) 296-6434 --------------------------------------------------- APPLICATION FOR COUNTY OR CITY ON SALE WINE LICENSE NOT TO EXCEED 14% OF ALCOHOL BY VOLUME --------------------------------------------------- EVERY QUESTION MUST BE ANSWERED. If a corporation, an officer shall execute this application. If a partnership, a partner shall execute this application. _________________________________|________________________________ Applicants Name Trade Name or DBA (Business, Partnership, Corporation) _________________________________|(___)___________|(___)__________ Business Address Business Phone Home Phone _________________________________|_____________|________|_________ City County State Zip Code Is this application |___________________________ If transfer, give name of [__] New [__] Renewal [__] Transfer former owner From_____________________________To_______________________________ License period *If corporation, give name, title, address and date of birth of each officer. If a partnership, give name, address and date of birth of each partner.* __________________________________|________________________|______ Partner/Officer Name and Title Address DOB __________________________________|________________________|______ Partner/Officer Name and Title Address DOB __________________________________|________________________|______ Partner/Officer Name and Title Address DOB __________________________________|________________________|______ Partner/Officer Name and Title Address DOB ------------ CORPORATIONS ------------ _______________|________________|______________| [__] Yes [__] No Date of Incorp. State of Incorp. Cert. Number __________________________________________________________________ If a subsidiary of another corporation, give name and address of parent corporation ----------------------- BUILDING AND RESTAURANT ----------------------- _________________________________|________________________________ Name of building owner Owner's address Are Property Taxes delinquent? [__] Yes [__] No Has the building owner any connection, direct or indirect with the applicant? [__] Yes [__] No Restaurant seating capacity ___________ Hours food will be available ___________ No. of people restaurant employs ___________ No. of months per year restaurant will be open ___________ Will food service be the principle business? [__] Yes [__] No __________________________________________________________________ Describe the premises to be licensed __________________________________________________________________ If the restaurant is in conjunction with another business (resort, etc.), describe business ------------------ OTHER INFORMATION ------------------ 1. Have the applicant or associates been granted an on-sale non- intoxicating malt beverage (3.2) and/or a "set-up" license in conjunction with this wine license? [__] Yes [__] No 2. 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? [__] Yes [__] No 3. During the past license year has a summons been issued under the liquor civil liability (Dram Shop) (M.S. 340A802) [__] Yes [__] No If yes, attach a copy of the summons. 4. Has the applicant or any of the associates in this application been convicted during the past five years of any violation of federal, state or local liquor laws in this state or any other state? [__] Yes [__] No If yes, give date and details. __________________________________________________________________ 5. Does any person other than the applicants, have any right, title or interest in the furniture, fixtures or equipment in the licensed premises? [__] Yes [__] No If yes, give name and address of the 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. ___________________________________________|______________________ Signature of Applicant Date ------------------------------------------------------------------ The Licensee must have one of the following: CHECK ONE [__] A. Liquor Liability Insurance (Dram Shop) - $50,000 per 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 OR THIS FORM. [__] B. A Surety bond from a surety company with minimum coverages OR as specified above in A. [__] C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a market value of $100,000 in cash or securities. ------------------------------------------------------------------ REPORT BY POLICE OR 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, Municipal or County. Ordinances relating to Intoxicating Liquor, except as follows ____ __________________________________________________________________ __________________________________________________________________ __________________________|______________|________________________ Police, Sheriff Dept. Name Date 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 612-290-3496.