Fill - Free fillable LICENSE APPLICATION City Of Duluth City Clerks Office PDF form

City of Duluth – City Clerk’s Office For Office Use Only

411 W First Street – City Hall 330 Date: __________________________

Duluth, MN 55802-1189 License No.____________________

Phone: (218) 730-5500

Fax: (218) 730-5923

LICENSE APPLICATION

GOVERNMENT DATA PRACTICES ACT -

CLASSIFICATION

WARNING: The data you supply on this form will be used to process the license you

are applying for. You are not legally required to provide this data, but we will not be able to process the license without it. Some of the data

will be classified as public data if and when the license is granted. Private financial information including a tax identification number and

social security number are classified as private data and will be available to governmental personnel and other governmental agencies

whose access is necessary to perform their official duties.

LICENSE

FEE

TEMPORARY ON SALE NON-INTOXICATING MALT LIQUOR

(BEER) – 1

ST

DAY =

$119.00

PLUS $23.00 EACH ADDITIONAL DAY =

$______________

TOTAL =

$______________

LICENSEE BUISNESS NAME & ADDRESS: TRADE NAME OR NAME OF EVENT:

______________________________________ ___________________________________________

______________________________________ BUISNESS PHONE NO: ______________________

______________________________________

MANAGER’S NAME & ADDRESS: OWNER OF BUSINESS PREMISES: ___________________

_____________________________________ __________________________________________________

_____________________________________ EVENT LICENSE DATE (S): __________________________

_____________________________________ __________________________________________________

Rain Date? Yes No If Yes, List Date: ___________________________________

Contact State Health Department at 723-4642 For Application for Beer and/or Food.

Security Personnel Questions? Call 730-5421

Will Dancing Be Allowed? Yes No If Yes, Contact City Clerk’s Office For Dancing License

Application

I HEREBY STATE THAT ALL INFORMATION HERE IS TRUE AND CORRECT AND THAT I SHALL COMPLY WITH ALL PROVISION

OF THE ORDINANCES OF THE CITY OF DULUTH AND LAWS OF THE STATE OF MINNESORTA AND THEIR AMENDMENTS.

_____________________________________________________________

SIGNATURE OF APPLICANT

MAILING ADDRESS

___________________________________________________

EMAIL: _____________________________________________

TEMPORARY EXPANSION OF LICENSED PREMISES (DIAGRAM)

Owner: ________________________________________ (d/b/a) Trade Name: _________________________________

Date of Event: ________________________ Address: ____________________________________________________

Name of Event: ____________________________________________ Time of Event: ___________________________

Security Personnel: _________________________________________ Firm: ___________________________________

DIAGRAM MUST SHOW:

A. Area that will be used.

B. Streets and intersections bordering the area.

C. W here fencing surrounding the area will be located and what type of fencing will be used (snow fence is

preferred).

D. Where the bar will be located in the “serving area.”

E. Exits and entries to and from the “serving area.”

Sketch location and dimensions of area to be occupied. Indicate north on diagram as “NORTH.”

I hereby agree that I shall comply with all of the ordinances of the City of Duluth and laws of the State of Minnesota and their

amendments. I further agree to comply with any special restrictions which may be imposed by resolution of the Duluth City

Council and not to allow any services or consumption outside of the approved “designated serving area” identified here.

_____________________________________________

Signature of owner/authorized representative

Date of Application __________

License No. _______________

CITY OF DULUTH

APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE

1. Name of Applicant (individual, partnership, corporation or association) that owns the business to be licensed:

___________________________________________________________________________________________

2. Trade Name: _____________________________________________________________________________

3. Address of place to be licensed: ______________________________________________________________

4. Designated Serving Areas (i.e. round floor, second, deck, etc.) ______________________________________

___________________________________________________________________________________________

5. Name and address of owner of building: ________________________________________________________

________________________________________________________

Any connection with applicant? __________________ Who receives the rent? ________________________

6. Who will direct the operation of the business or serve as manager on the premises?

List name, address & title: __________________________________________________________________

__________________________________________________________________

7. If partnership, give name of each partner and percentage of ownership, and, if limited partnership, give details:

___________________________________________ __________________________________________

8. If corporation, list all stockholders, directors, officers and the percentage of stock or number of shares owned by

each:

___________________________________________ __________________________________________

9. State approximate distance of this establishment from the nearest academy, college, university, church or school:

___________________________________________________________________________________________

10. State whether any consideration, money or property, has been paid, or will be paid, given, exchanged or pledged,

by anyone, and to whom, for the purchase or operation of this business. State the amounts in detail.

Failure to answer all questions truthfully on this application and Affidavit “A,” which is made a part thereof,

will be just cause for revocation of your license.

I (we) hereby certify that the applicant will be the sole owner and operator of this business to be conducted under the license and I (we)

will notify the City Council in writing of any change in ownership in this business before the change is made, for the approval of the

Alcohol, Gambling and Tobacco Commission and City Council. I (we) have read the foregoing questions and answers to said questions

are true of my (our) knowledge. I (we) will comply with all the provisions of the Alcoholic Beverage Code and the laws and regulations

of their amendments.

Signature: ____________________________________________________ Date: ___________________

- 1 of 2 -

CITY CLERK’S OFFICE AFFIDAVIT “A” ALCOHOLIC BEVERAGE

330 CITY HALL LICENSE APPLICATION

DULUTH, MN 55802

To be completed by each individual license, or each member of partnership, or two major stockholders

of a corporation, or two primary officers of a club and the person who will be directing the operation of the

business on the licensed premises.

NOTE: Type or print legibly and provide all information requested. Failure to do so may delay the

issuance of this license.

RENEWALS: If this affidavit is made relative to the annual renewal of an existing license, fill out items

1-4, and 11 & 12 of this application. Items 5-10 need be answered only as they relate to any changes

in your status since the filing of your last affidavit.

1. License Applicant

(Individual, Partnership, Corporation or Club)

2. Address of licensed premises ______________________________________________________

3. Your Name ____________________________________________________________________

(First) (Middle) (Last) ( Jr./Sr.) (Date of Birth)

4. Home Address _________________________________________________________________

(Address) (City) (County) (State) (Zip)

5. Other home addresses in last 10 years:

6. Other names you are, or have been known by, including maiden name: ______________________

7. Your position in the business: ______________________________________________________

(Owner, partner, president, treasurer, manager, etc.)

8. (a). Do you, your spouse, or your children have any pecuniary interest in the ownership, operation,

management or profits of any establishment license in Minnesota to sell liquor or 3.2 beer either at retail

or wholesale? Yes _______ No ______

(b). Do you, your spouse, or your children own stock in any corporation having a pecuniary interest

in the ownership, operation, management or profits of any establishment license in Minnesota to sell liquor

or 3.2 beer either at retail or wholesale? Yes ______ No ______

- 2 of 2 -

(c). If the answer to (a) or (b) is “yes”, state the location of the establishments involved and fully

describe the nature and extent of the interest. ____________________________________________

9. Furnish the names and addresses of at least three business references, including one bank reference:

(1) ______________________________________________________________________________

(2) ______________________________________________________________________________

(3) (Bank) ________________________________________________________________________

10. (a). Have you or any corporation in which you held more than 10% stock, ever been denied a

license to sell liquor or beer? Yes _____ No _____

If yes, why? ______________________________________________________________

(b). Have you or any corporation in which you held more than 10% of the stock ever had a liquor

or beer license suspended or revoked? Yes _____ No _____

If yes, why? ______________________________________________________________

11. Have you ever forfeited bail on or been convicted of violating any law relating to the operation of a bar

or the sale, distribution, manufacture or transportation of alcoholic beverages? Gambling laws?

Prostitution or disorderly house laws? Drug laws? Receiving or concealing stolen property? Assaults?

Yes _____ No _____

If yes, state the violation, where and when it occurred, the maximum possible penalty for the violation, and

whether or not the record of the conviction has been expunged. ______________________________

12. Have you read and do you understand the laws, rules and regulations of the State of Minnesota and

the City of Duluth relative to the sale and distribution of alcoholic beverages? Yes ____ No ____

I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE ABOVE ANSWERS ARE TRUE AND

CORRECT.

(WITNESS) (DATE) (APPLICANT’S SIGNATURE)

- 1 of 2 -

CITY CLERK’S OFFICE AFFIDAVIT “A” ALCOHOLIC BEVERAGE

330 CITY HALL LICENSE APPLICATION

DULUTH, MN 55802

To be completed by each individual license, or each member of partnership, or two major stockholders

of a corporation, or two primary officers of a club and the person who will be directing the operation of the

business on the licensed premises.

NOTE: Type or print legibly and provide all information requested. Failure to do so may delay the

issuance of this license.

RENEWALS: If this affidavit is made relative to the annual renewal of an existing license, fill out items

1-4, and 11 & 12 of this application. Items 5-10 need be answered only as they relate to any changes

in your status since the filing of your last affidavit.

1. License Applicant

(Individual, Partnership, Corporation or Club)

2. Address of licensed premises ______________________________________________________

3. Your Name ____________________________________________________________________

(First) (Middle) (Last) ( Jr./Sr.) (Date of Birth)

4. Home Address _________________________________________________________________

(Address) (City) (County) (State) (Zip)

5. Other home addresses in last 10 years:

6. Other names you are, or have been known by, including maiden name: ______________________

7. Your position in the business: ______________________________________________________

(Owner, partner, president, treasurer, manager, etc.)

8. (a). Do you, your spouse, or your children have any pecuniary interest in the ownership, operation,

management or profits of any establishment license in Minnesota to sell liquor or 3.2 beer either at retail

or wholesale? Yes _______ No ______

(b). Do you, your spouse, or your children own stock in any corporation having a pecuniary interest

in the ownership, operation, management or profits of any establishment license in Minnesota to sell liquor

or 3.2 beer either at retail or wholesale? Yes ______ No ______

- 2 of 2 -

(c). If the answer to (a) or (b) is “yes”, state the location of the establishments involved and fully

describe the nature and extent of the interest. ____________________________________________

9. Furnish the names and addresses of at least three business references, including one bank reference:

(1) ______________________________________________________________________________

(2) ______________________________________________________________________________

(3) (Bank) ________________________________________________________________________

10. (a). Have you or any corporation in which you held more than 10% stock, ever been denied a

license to sell liquor or beer? Yes _____ No _____

If yes, why? ______________________________________________________________

(b). Have you or any corporation in which you held more than 10% of the stock ever had a liquor

or beer license suspended or revoked? Yes _____ No _____

If yes, why? ______________________________________________________________

11. Have you ever forfeited bail on or been convicted of violating any law relating to the operation of a bar

or the sale, distribution, manufacture or transportation of alcoholic beverages? Gambling laws?

Prostitution or disorderly house laws? Drug laws? Receiving or concealing stolen property? Assaults?

Yes _____ No _____

If yes, state the violation, where and when it occurred, the maximum possible penalty for the violation, and

whether or not the record of the conviction has been expunged. ______________________________

12. Have you read and do you understand the laws, rules and regulations of the State of Minnesota and

the City of Duluth relative to the sale and distribution of alcoholic beverages? Yes ____ No ____

I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE ABOVE ANSWERS ARE TRUE AND

CORRECT.

(WITNESS) (DATE) (APPLICANT’S SIGNATURE)

- 1 of 2 -

CITY CLERK’S OFFICE AFFIDAVIT “A” ALCOHOLIC BEVERAGE

330 CITY HALL LICENSE APPLICATION

DULUTH, MN 55802

To be completed by each individual license, or each member of partnership, or two major stockholders

of a corporation, or two primary officers of a club and the person who will be directing the operation of the

business on the licensed premises.

NOTE: Type or print legibly and provide all information requested. Failure to do so may delay the

issuance of this license.

RENEWALS: If this affidavit is made relative to the annual renewal of an existing license, fill out items

1-4, and 11 & 12 of this application. Items 5-10 need be answered only as they relate to any changes

in your status since the filing of your last affidavit.

1. License Applicant

(Individual, Partnership, Corporation or Club)

2. Address of licensed premises ______________________________________________________

3. Your Name ____________________________________________________________________

(First) (Middle) (Last) ( Jr./Sr.) (Date of Birth)

4. Home Address _________________________________________________________________

(Address) (City) (County) (State) (Zip)

5. Other home addresses in last 10 years:

6. Other names you are, or have been known by, including maiden name: ______________________

7. Your position in the business: ______________________________________________________

(Owner, partner, president, treasurer, manager, etc.)

8. (a). Do you, your spouse, or your children have any pecuniary interest in the ownership, operation,

management or profits of any establishment license in Minnesota to sell liquor or 3.2 beer either at retail

or wholesale? Yes _______ No ______

(b). Do you, your spouse, or your children own stock in any corporation having a pecuniary interest

in the ownership, operation, management or profits of any establishment license in Minnesota to sell liquor

or 3.2 beer either at retail or wholesale? Yes ______ No ______

- 2 of 2 -

(c). If the answer to (a) or (b) is “yes”, state the location of the establishments involved and fully

describe the nature and extent of the interest. ____________________________________________

9. Furnish the names and addresses of at least three business references, including one bank reference:

(1) ______________________________________________________________________________

(2) ______________________________________________________________________________

(3) (Bank) ________________________________________________________________________

10. (a). Have you or any corporation in which you held more than 10% stock, ever been denied a

license to sell liquor or beer? Yes _____ No _____

If yes, why? ______________________________________________________________

(b). Have you or any corporation in which you held more than 10% of the stock ever had a liquor

or beer license suspended or revoked? Yes _____ No _____

If yes, why? ______________________________________________________________

11. Have you ever forfeited bail on or been convicted of violating any law relating to the operation of a bar

or the sale, distribution, manufacture or transportation of alcoholic beverages? Gambling laws?

Prostitution or disorderly house laws? Drug laws? Receiving or concealing stolen property? Assaults?

Yes _____ No _____

If yes, state the violation, where and when it occurred, the maximum possible penalty for the violation, and

whether or not the record of the conviction has been expunged. ______________________________

12. Have you read and do you understand the laws, rules and regulations of the State of Minnesota and

the City of Duluth relative to the sale and distribution of alcoholic beverages? Yes ____ No ____

I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THE ABOVE ANSWERS ARE TRUE AND

CORRECT.

(WITNESS) (DATE) (APPLICANT’S SIGNATURE)

CITY OF DULUTH

CITY CLERK’S OFFICE

330 City Hall

411 West First Street

Duluth, Minnesota 55802-1189

Phone (218) 730-5500

Fax (218) 730-5923

TO: All Temporary 3.2 On Sale Malt Liquor and Temporary On Sale Intoxicating

Liquor Applicants

SUBJECT: Minnesota Statutes - 340A.909 - Sale of Minnesota Beer at Public

Facilities.

Subdivision 1. Minnesota-produced beer, required availability. At any permanent

or temporary building or structure owned or operated by the state, a political subdivision, or

an instrumentality thereof, where beer is sold for on-premise consumption, the entity owning

or operating the building or structure must insure that a Minnesota-produced beer is available

for purchase at each station where beer is sold. This section applies to all such permanent

or temporary buildings or structures without regard to whether sales of beer are made by the

owning or operating government entity or employees thereof or by a person holding a lease

or concession contract with the government entity.

K:\CLERKDOC\LICENSES\Current Licenses\templiq_Supplemental_Form.wpd

CITY OF DULUTH

SUPPLEMENTAL FORM

Additional information is being required by the Duluth Police Department. An incomplete

application will result in the delay or rejection of your application.

1. Is this the first time for this event? Yes No

If No, how many people attended this event ____________

If Yes, how many people are you expecting to attend? ____________

2. What kind of advertisement have you done? _______________________________

3. What is the age of the target group for this event? ____________

4. Will alcohol be sold or given away at this event? ____________

5. Will dancing be allowed at this event? ____________

I understand that as the applicant for this permit/license, I am responsible for the

Police/Security for this event. I will provide proof of hired security two weeks prior to the

scheduled event.

________________________________________ ____________

Applicant Signature Date

For office use only

Is a licensed Peace Officer needed for this event? _____________________

If yes, how many licensed peace officers will be required? _______________

CITY OF DULUTH

CITY CLERK’S OFFICE

330 City Hall

411 West First Street

Duluth, Minnesota 55802-1189

Phone (218) 730-5500

Fax (218) 730-5923

TO: Alcoholic Beverage Licensee

RE: Liquor Liability Insurance Requirements.

Please note that Minnesota Statutes 340A.409 reads in part as follows:

Subd. 1. Insurance required. No retail license may be issued, maintained or renewed unless the

applicant demonstrates proof of financial responsibility with regard to liability imposed by Section 340A.801.

The issuing authority must submit to the commissioner the applicant’s proof of financial responsibility.

Subd. 4. Insurance not required. Subdivision 1 does not apply to licensees who by affidavit establish

that:

(1) they are on-sale 3.2 percent malt liquor licensees with sales of less than $25,000 of 3.2 percent malt

liquor for the preceding year;

(2) they are off-sale 3.2 percent malt liquor licensees with sales of less than $50,000 of 3.2 percent malt

liquor for the preceding year;

(3) they are holders of on-sale wine licenses with sales of less than $25,000 for wine for the preceding

year;

(4) they are holders of temporary wine licenses issued under law...

AFFIDAVIT OF SALES FOR EXEMPTION OF THE REQUIREMENT

OF LIQUOR LIABILITY INSURANCE

YES NO

1. In the past license year, has the licensed establishment sold

$25,000 or more on-sale non-intoxicating malt liquor or wine?

2. In the past license year, has the licensed establishment sold

$50,000 or more of off-sale non-intoxicating malt liquor?

3. Do you anticipate selling more than $25,000 of either on-sale

wine or non-intoxicating malt liquor, or $50,000 of off-sale non-

intoxicating malt liquor in the upcoming license year?

IF ‘YES’ IS ANSWERED TO ANY OF THE ABOVE QUESTIONS, YOU WILL NEED TO PROVIDE US WITH

A CERTIFICATE OF INSURANCE.

Trade Name: Date:

Signature of Licensee or Authorized Representative:

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