Fill - Free fillable 3.2On-SaleOff-SaleBeerLicense2019Fillable1 City of Farmington PDF form

CITY OF FARMINGTON

LICENSE PROCESS

3.2 On-Sale / Off-Sale Beer License

Retail on-sale 3.2 beer licenses can only be issued to drugstores, restaurants, hotels, clubs and establishment

for the sale of non-intoxicating malt beverages, all forms of tobacco, beverages and soft drinks at retail.

Retail off-sale 3.2 beer license spermit the licensee to sell non-intoxicating malt liquors in original packages

for consumption off the premises only.

Please review Title 3 Chapter 2 of the city code for complete details. All licenses expire December 31 of

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

1. Application forms, fees a Certificate of Insurance showing liquor liability coverage through

December 31 of the current year, or affidavit of gross annual sales, should be submitted to the city of

Farmington at least one week prior to a Council meeting.

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

3. The application will be submitted to the City Council for approval. 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 and a license is

issued. The state can take up to one week to approve it. The applicant should submit an application

to the state for a Buyer’s Card which allows them to purchase beer to sell. The entire application

process takes approximately three weeks.

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

Off-Sale Beer $75/year

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/Off-Sale Beer 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. Workers’ Comp. Certificate of Compliance (Form FGTN2009) ____________ ____________

4. Malt Liquor Beverages Affidavit of Gross Annual Sales _________ __________

5. Ordinances 3-2-7 & 3-2-8 __________ ___N/A____

6. All applicable Fees (See fee schedule below) __________ __________

7. Certificate of liability insurance __________ __________

8. Floor plan of premises __________ __________

9. Application for Retailer’s (Buyer’s) Card Applicant sends form directly to State of

MN Alcohol and Gambling Enforcement Division

3.2. On-Sale / Off-Sale Beer License Fees

Beer, Off-Sale $75/Year

Beer, On-Sale $250/Year

Application for City 3.2 On-Sale / Off-Sale Beer 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 ________ 3.2 Off-Sale 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

______ Retail / Convenience Store

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

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

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

click to sign

signature

click to edit

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: ________________________

click to sign

signature

click to edit

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

MALT LIQUOR BEVERAGES

AFFIDAVIT OF GROSS ANNUAL SALES

(For 3.2% On-Sale / Off-Sale Beer License Applicants Only)

I, the undersigned, hereby certify that the prior year’s gross annual sales of on-sale malt liquor beverages

did not exceed ten thousand dollars ($10,000) or off-sale malt liquor beverages did not exceed twenty

thousand dollars ($20,000) at the following establishment.

Further, at such time during the term of the license period, gross sales of on-sale malt liquor beverages shall

equal ten thousand dollars ($10,000) or off-sale malt liquor beverages gross sales shall equal twenty

thousand dollars ($20,000), all further sales of malt liquor beverages shall cease until proof of financial

responsibility by Title 3, Chapter 12, Section 9 of the Farmington City Code is demonstrated.

Place of Business: _____________________________________________________________

Signature: __________________________________________ Date: _________________

Subscribed and sworn to before me this ______ day of _______________________, ________.

Signature of Notary Public __________________________________________

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

3.2On-SaleOff-SaleBeerLicense2019Fillable1 City of Farmington

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank 3.2On-SaleOff-SaleBeerLicense2019Fillable1 City of Farmington Form

Related forms

Fillable 3.2On-SaleOff-SaleBeerLicense2019Fillable1 City of Farmington

Fill Online, Printable, Fillable, Blank 3.2On-SaleOff-SaleBeerLicense2019Fillable1 City of Farmington Form

Related forms

First 20 documents completely FREE!