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ConsumptionandDisplayPermit2019Fillable1 City of Farmington

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CITY OF FARMINGTON
LICENSE PROCESS
Consumption and Display Permit
A consumption and display permit is issued to a business and allows individuals to bring in their own liquor for
consumption on the premises. The business owner cannot sell or store liquor on the premises. Please review
Title 3 Chapter 11A of the city code for complete details. All licenses expire December 31 of each year.
Following is the process to obtain a consumption and display permit:
1. Application forms and fees should be submitted to the city of Farmington.
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 entire application process takes approximately four
weeks.
5. Fees: Consumption and Display Permit $300/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 Consumption and Display Permit
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 Consumption and Display Application ____________ ____________
2. State License Application __________ __________
3. Workers’ Comp. Certificate of Compliance ____________ ____________
4. All applicable Fees (See fee schedule below) ____________ ____________
Consumption and Display Permit Fees
Consumption and Display Permit $300
Investigation Fee $100
State Fee $250
(Paid to the state)
Application for Consumption and Display Permit
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 _____________________________
Type of Business Restaurant ______ Hotel ______ Other _________________________________
Trade Name or DBA: ____________________________________________________________________
Business Name: _______________________________________________________________________
(Business, partnership, LLC, corporation)
Business Address:______________________________________________________________________
(Street) (City, State, ZIP) (County)
Business Phone: ___________________________ Home Phone:____________________
Email: ____________________________________ Cell 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 had 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 Does 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 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 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 business will be open: _________________________________________________________
Number of people business employs: _____
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
NOTE: ALL CLUB ‘ON-SALE’ INTOXICATING LIQUOR LICENSEES ARE EXEMPT FROM APPLYING.
APPLICATION FOR CONSUMPTION AND DISPLAY (Set Up) PERMIT
PERMIT FEE $250 (Permits expire March 31
st
of each year)
Workers Comp. Ins. Co. ________________________________________________
Policy No. ___________________________ Dates of Coverage ______________
Licensee’s MN Sales & Use Tax ID # __________________________ To apply for MN Tax ID # 651-296-6181
A $30 service charge will be added to all dishonored checks.
Licensee’s Federal Tax ID # __________________________ You may also be subjected to civil penalty of $100 or 100% of the
value of the check, whichever is greater, plus interest and attorney fees.
Applicants Full Name (Business, Partnership, LLC, corporation)
DOB
SS#
Business Street Address
County
City
State
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 _____ Yes
premises separate from any _____ No
other business establishment?
Is there a current 3.2 ____Yes
beer license issued ____ No
to this business at this location?
Is Application
____ Original
____ Transfer
If transfer, former license and
business trade name
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 _______________________________________________________ Date ______________
(Signature certifies all above information to be correct and permit has been approved by city/county).
City/County Auditor Signature ______________________________________________ Date ______________
(Signature certifies all above information to be correct and permit has been approved by city/county).
Minnesota Department of Public Safety
Alcohol and Gambling Enforcement Division
445 Minnesota Street, Suite 222
St. Paul, MN 55101
651-201-7500 Fax 651-297-5259 TDD 651-282-6555
Amount Received
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Completed 12 July 2020

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