Fill - Free fillable 3.2On-SaleBeerandWineLicense2019Fillable1 City of Farmington PDF form

CITY OF FARMINGTON

LICENSE PROCESS

3.2 On-Sale Beer and Wine License

Strong Beer License

Wine licenses can be issued to restaurants for the sale of wine not exceeding 14% alcohol. A holder of a

wine license who is also licensed to sell on-sale 3.2 beer and whose gross receipts are at least 60%

attributable to the sale of food, is authorized to sell intoxicating malt liquor at on-sale without an additional

license. Please review Title 3 Chapter 12 Section 4E of the City Code. All licenses expire December 31 of

each year. Following is the process to obtain a 3.2 on-sale beer and wine license:

1. Application forms, fees, and a Certificate of Insurance showing liquor liability through December 31

of the current year should be submitted to the City of Farmington.

2. A background check will be performed by the Farmington Police Department.

3. A public hearing is required to be held at a City Council meeting. The public hearing requires 10

days notice prior to the meeting. The public hearing notice is submitted to the newspaper a week

prior to this 10-day period. Council meetings are held the first and third Mondays of every month.

4. Upon City Council approval, the application is submitted to the State for approval. The State can

take up to one week to approve it. At this time, the applicant should submit an application to the

state for a Buyer’s Card which enables them to buy wine and beer to sell. Upon State approval, a

license is issued. The entire application process takes four weeks.

5. Fees: On-Sale Beer $250/year

Wine $300/year

Wine License Investigation Fee $100

Total Fees: $650

If you have questions, please contact:

Cynthia Muller, Administrative Assistant

City of Farmington

430 Third Street

Farmington, MN 55024

Tel: 651-280-6803

E-mail: CMuller@FarmingtonMN.gov

Checklist for 3.2 On-Sale Beer & Wine License

Business Name: _________________________________________

Please return this list with your application materials. Incomplete applications cannot be

processed until all of the items listed are received and complete.

Required Applicant City Staff

Documents Initials Initials

1. City of Farmington Liquor License Application (Form LLIC2009) ____________ ____________

2. State License Certification Form (Form 9011-5/06) __________ __________

3. Application for City/County On-Sale Wine License __________ __________

4. Workers’ Comp. Certificate of Compliance (Form FGTN2009) ____________ ____________

5. All applicable Fees (See fee schedule below) ____________ ____________

6. Certificate of liability insurance __________ __________

7. Floor plan of premises __________ __________

8. Application for Retailer’s (Buyer’s) Card for Liquor/Wine* *Applicant sends form directly to State

of MN Alcohol and Gambling Enforcement Division

3.2. On-Sale Beer and Wine License Fees

3.2. On-Sale Beer $250/year

On-Sale Wine $300/year

Wine Investigation Fee $100

(Not charged for renewals)

Application for City 3.2 On-Sale Beer and Wine License

(Form LLIC2009)

EVERY QUESTION MUST BE ANSWERED UNLESS OTHERWISE NOTED

If a corporation, an officer must execute this application; if a partnership, LLC, a partner must execute this application.

APPLICANT INFORMATION

Type of License Requested _______ 3.2.On-Sale Beer ________ Wine _______ Strong Beer

Applicant’s Full Name: __________________________________________ Date of Birth ____/___/_____

(First) (Full Middle Name) (Last)

Are you a U.S. citizen? ____ Yes ____ No Naturalized? ___Yes ___No

If yes, date/place _____________________________

Type of Business ______ Restaurant ______Hotel ______ Bowling Alley ______ Billiard Parlor

Trade Name or DBA: ____________________________________________________________________

Business Name: _______________________________________________________________________

(Business, partnership, LLC, corporation)

Business Address:______________________________________________________________________

(Street) (City, State, ZIP) (County)

Business Phone: ___________________________ Applicant’s Home Phone:______________________

Workers Compensation Insurance Company Name: ________________________ Policy # ___________

Licensee’s MN Sales & Use Tax ID # _____________________ Federal Tax ID # ___________________

CORPORATIONS

If a corporation, give name (first, middle & last), title, address and date of birth for each officer. If a

partnership, LLC, give name, address and date of birth of each partner:

Partner/Officer Full Name & Title Address DOB

__________________________________ _________________________________ __________

Date of Incorporation ___/____/________ State ________ Certificate Number ___________________

Is corporation authorized to do business in Minnesota? _____Yes _____No

If a subsidiary of another corporation, give name and address of parent corporation: __________________

_____________________________________________________________________________________

OTHER INFORMATION

Names (first, middle & last), and addresses of all persons who will own or be actively or inactively involved

in the management of the establishment where the license will be used.

NOTE: The location manager must be listed.

Full Name & Title Address DOB

__________________________________ ____________________________ ____________________

Please answer all of the following:

___Yes ___No Has the applicant, partners, officers or employees ever has any Liquor Law violations

in Minnesota or elsewhere, including State Liquor Control Penalties? If yes, please

attach explanation with date, charges and final outcome.

___Yes ___No During the past license year, has a summons been issued under the Liquor Civil

Liability Law (Dram Shop) M.S. 340A.802. If yes, please attach a copy of the

summons.

___Yes ___No Has the applicant, partners, officers or employees had an intoxicating liquor license

within five years of this application?

___Yes ___No Do the applicant have any interest, directly or indirectly, in any other liquor

establishments in Minnesota? If yes, please give the name and address of the

establishment(s).

___Yes ___No Does any person other than the applicants listed here, have any right, title or interest

in the furniture, fixtures or equipment in the licensed premises? If yes, attach the

names and details.

___Yes ___No Will you serve liquor on Sunday?

___Yes ___No Do you acknowledge review of the Farmington City Code Chapter 3 regarding

alcoholic beverages? (Can be viewed on the City’s website, or paper copies are

available upon request.)

LOCATION / RESTAURANT INFORMATION

Name of building owner: ___________________ Owner’s address:_______________________________

Does the building owner have any connection, direct or indirect, with the applicant? ___Yes ___No

Are property taxes current? ___Yes ___No Posted occupant load of establishment: ____________

Are there any plans currently pending or anticipated for the sale or transfer of the business or premises for

which the license is applied? ___Yes ___ No

Days/hours food will be available: _________________________________________________________

Number of people restaurant employs: _____ Will food service be the principal business? ___Yes ___No

I certify that I have read this entire application and that the responses given are true and correct to the best

of my knowledge. I am aware that any misrepresentation in such responses may result in rejection of this

application. I authorize the City of Farmington to investigate the information and contact

persons/organizations named on this application.

Name of Applicant (please print) ___________________________________________________

Title _________________________________________________________________________

Signature _________________________________________________Date _______________

Subscribed and sworn to before me this _______ day of _______________, ________.

Signature of Notary Public __________________________________

APPROVALS

Department Signature Date Comments

Police ______________________ __________ _____________________________

City Clerk/Deputy Clerk_____________________ __________ _____________________________

Please return completed application to: City of Farmington

Attn: Liquor Licensing

430 Third Street

Farmington, MN 55024

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CITY OF FARMINGTON

GENERAL AUTHORIZATION AND RELEASE OF DATA

In order to comply with State and Federal Data Privacy Act Laws, the City of Farmington is requesting your

authorization and consent to permit the City to conduct a background investigation. Please provide the

following personal data, read the paragraphs below and sign where indicated.

Full Name: ____________________________________________________________________

(First, Middle, Last)

Address: ______________________________________________________________________

Number Street City County State Zip Code

Date of Birth: _________________ Driver’s License Number: __________________________

Month/Date/Year

Have you ever been convicted of any crime, either felony or misdemeanor? ________ If yes, please state

place and nature of offense: _____________________________________________

______________________________________________________________________________

I, the undersigned, hereby authorize and grant my informed consent to permit the Bureau of Criminal

Apprehension (hereafter “BCA”) and the Farmington Police Department (hereafter “FPD”) to release to and

make available to the City of Farmington, Minnesota (hereafter “City”) and/or its representatives all data

classified as private which concerns me and which may be in your possession. The data, classified as

private under M.S. 13.02, Subd. 12, includes all data which has been collected, created, received, retained or

disseminated in whatever form which in any way relates to my dealings with the BCA and/or the FPD. I

understand the purpose of permitting the City to have access to this information is to determine my

suitability for licensure.

By signing this authorization, I hereby release the BCA and the FPD from any and all liability which

otherwise may or does accrue as a result of the release of any and all data, regardless of its accuracy. I also

release the City from any and all liability for its receipt and use of data received pursuant to this consent. I

understand that if I am rejected on the basis of a criminal conviction, I will be notified in writing and be

given rights of redress subject to applicable laws. I also understand that I am not legally required to sign

this form, but if I do not, the City will not be able to determine whether my conviction record is a license-

related consideration.

This authorization shall be valid for a period of one year, but I reserve the right, at any time prior to that

expiration, to cancel the written authorization by providing written notice to the City of that intent.

_______________________________________________ ________________________

(Signature) (Date)

_______________________________________________

(Full Name Printed)

Please return to:

City of Farmington

Attn: Administration

430 Third Street

Farmington, MN 55024

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CITY OF FARMINGTON – DATA PRACTICES ACT NOTICE

Minnesota law requires that you be informed of your rights as they pertain to private information (“private

data”) collected from you by the City of Farmington (“the City”). Private data is that information held by

the City which is available to you, but not to the public.

You have the right to refuse to provide the information requested on this application form, however, without

certain information, the City may be unable to approve the license applied for. If you feel that certain

information requested is an unwarranted invasion of privacy, please contact the Human Resources Director.

The dissemination and the use of private data we collect is limited to that necessary for the administration

and management of the City’s licensing program. Persons or agencies with whom this information may be

shared include:

 City personnel, including law enforcement personnel, administering the license program;

 The Bureau of Criminal Apprehension;

 The City Attorney and support staff of the City Attorney’s office;

 Federal, state, local, and contracted private auditors;

 Federal and State agencies with oversight or responsibility related to the licensed business;

 Those individuals or agencies as to whom you give your express written permission for release of

the information.

Unless otherwise authorized by state statute or federal law, other governmental agencies utilizing the

reported private data must also treat the information as private.

You may wish to exercise your rights as contained in the Minnesota Government Data Practices Act. These

rights include:

 The right to see and obtain copies of data maintained about you;

 The right to be told the contents and meaning of the data; and

 The right to contest the accuracy and completeness of the data.

To exercise these rights, contact the Farmington Human Resources Director at 430 Third Street,

Farmington, MN 55024 (651) 280-6800. I have read and I understand the above information regarding my

rights as a subject of government data.

___________________________________________ _______________________

Applicant Date

CERTIFICATION OF COMPLIANCE

MINNESOTA WORKERS’ COMPENSATION LAW

Form FGTN2009

Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold

the issuance or renewal of a license or permit to operate a business or engage in an activity in

Minnesota until the applicant presents acceptable evidence of compliance with the workers’

compensation insurance coverage requirement of Chapter 176. The information required will be

collected by the licensing agency and retained in their files. The information required is: name of

insurance company, policy number, and dates of coverage or permit to self-insure.

This information is required by law, and licenses and permits to operate a business may

not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this

information is not provided or falsely stated, it may result in a $2,000 penalty assessed

against the applicant by the Commissioner of the Department of Labor and Industry.

Insurance Company Name: ______________________________________________________

(Not the insurance agent)

Policy Number: ________________________________________________________________

Dates of Coverage: ____________________________ to ______________________________

(or)

I am not required to have workers’ compensation liability coverage because:

( ) I have no employees.

( ) I am self-insured (include permit to self-insure).

( ) I have no employees who are covered by the workers’ compensation law,

(these include: spouse, parents, children and certain farm employees).

I certify that the information provided above is accurate and complete and that a valid workers’

compensation policy will be kept in effect at all times as required by law.

Name: ________________________________________________________________________

(Last) (Middle) (First)

Doing business as (DBA): _______________________________________________________

(Business name if different than your name)

Business address: _____________________________________________________________

(Street) (City, State, ZIP)

Phone: _________________________ Email: ________________________________________

Signature: _______________________________________Date: ________________________

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176.182 BUSINESS LICENSES OR PERMITS; COVERAGE REQUIRED

Every state and local licensing agency to withhold the issuance or renewal of a license or

permit to operate a business in Minnesota until the applicant presents acceptable evidence of

compliance with the workers’ compensation insurance coverage requirement of Section 176.181,

subdivision 2, by providing the name of the insurance company, the policy number, and the dates

of coverage or the permit to self-insure. The commissioner shall assess a penalty to the employer

of $2,000 payable to the assigned risk safety account, it the information is not reported or is falsely

reported.

Neither the state nor any governmental subdivision of the state shall enter into any contract

for the doing of any public work before receiving from all other contracting parties acceptable

evidence of compliance with the workers’ compensation insurance coverage requirement of

Section 176.181, subdivision 2.

This section shall not be construed to create any liability on the part of the state or any

governmental subdivision to pay workers’ compensation benefits or to indemnify the special

compensation fund, an employer, or insurer who pays workers’ compensation benefits.

HIST: 1982 c 346 s 94; 1983 c 290 s 114; 1987 c 332 c 332 s 47; 1992 c 510 art 3 s 19; 1995 c

231 art 2 s 72

Certification of an On Sale Liquor License, 3.2% Liquor License, or Sunday Liquor License

Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor license

types: 1) City issued on sale intoxicating and Sunday liquor licenses

2) City and County issued 3.2% on and off sale malt liquor licenses

Name of City or County Issuing Liquor License _________________________ License Period From: _________To: _________

Circle One: New License Renewal License Transfer ______________________ Suspension Revocation Cancel __________

(former licensee name) (Give dates)

License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On Sale 3.2% Off Sale

Fee: On Sale License fee: $ _______ Sunday License fee: $_______ 3.2% On Sale fee: $______ 3.2% Off Sale fee: $_______

Licensee Name: __________________________________________ DOB_____________ Social Security #________________

(corporation, partnership, LLC, or individual)

Business Trade Name _____________________________ Business Address____________________ City __________________

Zip Code___________ County ____________ Business Phone___________________ Home Phone_______________________

Home Address_____________________________ City _______________________ Licensee’s MN Tax ID#________________

(To Apply call 651-296-6181)

Licensee’s Federal Tax ID#______________________________

(To apply call IRS 800-829-4933)

If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer:

Partner/Officer Name (First Middle Last) DOB Social Security # Home Address

Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must

contain all of the following:

1) Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license.

2) Cover completely the license period set by the local city or county licensing authority as shown on the license.

Circle One: (Yes No) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law?

Workers Compensation Insurance is also required by all licensees: Please complete the following:

Workers Compensation Insurance Company Name: ________________________________ Policy #_______________________

I certify that this license has been approved in an official meeting by the governing body of the city or county.

City Clerk or County Auditor Signature_______________________________________________ Date________________

(title)

On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the application for the Buyers

Card, please call 651-201-7504, or visit our website at www.dps.state.mn.us.

(Form 9011-12/09)

Minnesota Department of Public Safety

Alcohol and Gambling Enforcement Division (AGED)

445 Minnesota Street, Suite 222, St. Paul, MN 55101-5133

Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555

EVERY QUESTION MUST BE ANSWERED. If a corporation, an officer shall execute this application. If a

partnership, LLC, a partner shall execute this application.

Workers compensation insurance company. Name __________________________ Policy # ____________

LICENSEE’S MN SALES & USE TAX ID #_________________ To apply for MN Sales Tax # call (651)296-6181

LICENSEE’S FEDERAL TAX ID #___________________________

Applicants Name (Business, Partnership, corporation)

Trade Name or DBA

Business Address

Business Phone

Applicant’s Home Phone

City

County

State

Zip Code

Is this application

New __ Transfer ___ Renewal

If a transfer, give name of former

owner

License Period

From_________ To___________

If a corporation, give name, title, address and date of birth of each officer. If a partnership, LLC, give name, address

and date of birth of each partner.

Partner/Officer Name and Title

Address

Social Security #

DOB

Partner/Officer Name and Title

Address

Social Security #

DOB

Partner/Officer Name and Title

Address

Social Security #

DOB

Partner/Officer Name and Title

Address

Social Security #

DOB

CORPORATIONS

Date of Incorporation

State of Incorporation

Certificate Number

Is corporation authorized to do business in

MN? Yes ______ No ________

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

Number of people

restaurant employs

Number 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

NO LICENSE WILL BE APPROVED OR RELEASED UNTIL THE $20 RETAILER ID CARD FEE IS RECEIVED BY AGED

Minnesota Department of Public Safety

ALCOHOL AND GAMBLING ENFORCEMENT DIVISION

444 Cedar St., Suite 222, St. Paul, MN 55101-5133

(651) 201-7507 FAX (651) 297-5259 TTY (651) 282-6555

www.dps.state.mn.us

APPLICATION FOR COUNTY/CITYON-SALE WINE LICENSE

(Not to exceed 14% of alcohol by volume)

OTHER INFORMATION

____ Yes ____ No

1. Has 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? 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).

____ Yes ____ No

3. During the past license year, has a summons been issued under the liquor civil liability

(Dram Shop)(M.S. 340A.802). If yes, attach a copy of the summons.

____ Yes ____ No

4. Has applicant, partners, officers or employees ever had any liquor law violations in

Minnesota or elsewhere? If so, give names, dates, violations and final outcome.

____ Yes ____ No

5. Does any person other than the applicants, have any right, title or interest in the furniture,

fixtures or equipment in the licensed premises? If yes, give names and details.

____ Yes ____ No

6. Have the applicants any interests, directly or indirectly, in any other liquor establishments

in Minnesota? 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

The licensee must have one of the following: (check one)

____A. 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.

____B. A surety bond from a surety company with minimum coverage 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 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 Date

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:

_______________________________________________________________________________________________________

____________________________________ _____________________________ ___________

Signature Department and Title Date

IMPORTANT NOTICE

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.

NOTICE

A $30 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100 or 100% of the

value of the check, whichever is greater, plus interest and attorney fees.

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