Fill - Free fillable BrewPubLicense2019Fillable1 City of Farmington PDF form

CITY OF FARMINGTON

LICENSE PROCESS

Brew Pub License

A brew pub license can only be issued to applicants who already have an on-sale intoxicating liquor or 3.2

beer/wine license. Please review Title 3 Chapter 12 of the city code for complete details. All licenses

expire December 31 of each year. Following is the process to obtain a brew pub license:

1. Application forms, fees and a Certificate of Insurance showing liquor liability coverage 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 and a license is

issued. The state can take up to one week to approve it. The entire application process takes

approximately four weeks.

5. Fees: Brew Pub License $250/year

Investigation Fee $100

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 Brew Pub License

Applicant must have an on-sale intoxicating liquor or 3.2 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 Brew Pub License Application ____________ ____________

2. State Form Brew Pub Off-sale (if applicable) __________ __________

3. Copy of On-Sale Intoxicating Liquor or 3.2 Beer/Wine License __________ ___________

4. Workers’ Comp. Certificate of Compliance ____________ ____________

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

6. Certificate of liability insurance __________ __________

7. Floor plan of premises __________ __________

Brew Pub License Fees

Brew Pub Fee $250/year

Investigation Fee $100

(Not charged for renewals)

Application for Brew Pub License

Applicant must have an on-sale intoxicating liquor or 3.2 beer/wine license first.

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

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 _____________________________

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

APPLICATION FOR BREW PUB OFF SALE

INTOXICATING LIQUOR LICENSE

Must be a licensed brew pub in order to apply for this license

Fees: Brew Pub Off Sale Fee: $ _________ Sunday License: YES ____ NO ____ Sunday License Fee: $ ________

Workers Comp Ins Co _______________________________________________ Policy Number ______________

Minnesota Tax ID Number ______________________________ Federal Tax ID Number ______________________

Licensee’s Name (business, partnership, LLC, corporation)

DOB

Social Security Number

DBA or Trade Name

Business address

Phone Number

Fax Number

City

State

Zip Code

License Period

From To

Name of Store Manager

Phone Number

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.

Partner Officer (first, middle, last)

DOB

SS#

Title

Business Address

Partner Officer (first, middle, last)

DOB

SS#

Title

Business Address

Partner Officer (first, middle, last)

DOB

SS#

Title

Business Address

Partner Officer (first, middle, last)

DOB

SS#

Title

Business Address

1. If a corporation, date of incorporation ________________________, state incorporated in _______________,

amount paid in capital ______________ . If a subsidiary of any other corporation, so state _______________

and give purpose of corporation _______________________. If incorporated under the laws of another state,

is corporation authorized to do business in the state of Minnesota? YES _____ NO ______

2. Describe premises to which license applies; such as (first floor, second floor, basement, etc.) or if entire

building, so state. _________________________________________________________________________

3. Is establishment located near any state university, state hospital, training school, reformatory or prison?

YES _____ NO ______ If yes, state approximate distance _______________________________________

4. Name and address of building owner: _________________________________________________________

________________________________________________________________________________________

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? YES ______ NO ______ 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 whatsoever, directly or indirectly, in any other liquor establishment in the state of

Minnesota? YES _____ NO _____ If yes, give name and address of establishment. ___________________

________________________________________________________________________________________

8. Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any

other business establishment? YES _____ NO ______

Minnesota Department of Public Safety

Alcohol and Gambling Enforcement Division

445 Minnesota Street, Suite 222, St. Paul, MN 55101-2156

651-201-7531 Fax 651-297-5259 TTY 651-282-6555

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 same premises. YES ______ NO _______ Will be granted ______

10. State whether applicant has or will be granted a Sunday on-sale liquor license in conjunction with the regular

on-sale liquor license. YES ______ NO ______ 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, including state liquor penalties? YES ______ NO ______ 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? YES ______ NO ______ If yes, attach a copy of the summons.

______________________________________________________________________________________________

This license must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM).

Check One

_____ 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 minimum 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

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