Fillable LIQUOR LICENSE APPLICATION CHECKLIST Applicant is required to (City of Duluth)

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LIQUOR LICENSE APPLICATION CHECKLIST Applicant is required to (City of Duluth)

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LIQUOR LICENSE APPLICATION CHECKLIST
Applicant is required to attend the Alcohol, Gambling, and Tobacco Commission (AGTC) meeting, which
meets the first Wednesday of each month. Application and fee to be filed in the City Clerk’s Office one
week prior to the meeting.
The AGTC will make a recommendation to the city council for approval. The council’s approval will be sent
to the Alcohol, Gambling, and Tobacco Division (AGED) of the Minnesota Department of Public Safety.
Upon approval, AGED will issue your buyer’s card.
TO BE TURNED IN WITH INITIAL APPLICATION
Fully Completed License Application: Incomplete applications will not be accepted.
License Fee: Refer to page 2. Check should be written to the City of Duluth.
Personal Supplemental Affidavit (multiple): To be completed by each individual licensee, each member of
a
partnership, two major stockholders of a corporation, two primary officers of a club, and
the person who will be
directing the operation of the business on the licensed premises. Three are attached.
MN DPS Alcohol & Gambling Enforcement Certification form: See Clerk’s Office for correct form.
MN DPS Alcohol & Gambling Enforcement Buyer’s Card Application (attached)
Buyer’s Card Fee: $20 check made payable to AGED
TO BE TURNED IN PRIOR TO APPROVAL BY CITY COUNCIL
Certificate of Liquor Liability Insurance: Coverage must run concurrent with the license period of September 1
through September 1 or state “Continuous Until Cancelled” – or – Dram Shop Insurance exemption (for On-Sale
and Off-Sale 3.2 malt liquor licenses). Refer to example on page 4.
Corporate documentation: including stock ownership and Articles of Incorporation must be filed prior to
issuance of license.
Certificate of Workers Compensation Insurance (attached)
MN Statute 270C.72 Tax Identification Form (attached)
TO BE DONE PRIOR TO FINAL APPROVAL
Sales Tax application filed with the City of Duluth Finance Office: They are located on the first floor of City Hall
(218-730-5350). If this is a transfer, the taxes must be paid in full (from previous owner) before license can be
issued.
Health Department: Approval must be obtained by the Minnesota Department of Health. Please provide a copy
of the Health Department license.
Fire Department : Approval and Certificate of Occupancy must be obtained by the Fire Department. Any issues of
fire code violations must be taken care of before license can be issued. (218-730-4398)
Wine and Off Sale Liquor: Call the State at 651-296-9519 for inspection of the site.
Property Taxes: Must be paid up to date, prior years and current.
Purchase Agreement: If a transfer, a copy of the signed Purchase Agreement is required before a resolution will
be filed with City Council.
City of Duluth New Liquor License Application – Updated 10/15/2019
P
age 1
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TYPE OF LICENSE
(Check all that apply)
License Type
Fee
(including investigation fee)
License Type Fee
Off-Sale Intoxicating $1709.00 Brewery Off-Sale $250.00
On-Sale Intoxicating $4526.00 Brewery Taproom On-Sale $300.00
Sunday Liquor $178.00 Microdistillery Off-Sale $250.00
Wine (Includes Sunday) $1101.00 Microdistillery Cocktail Room $300.00
3.2% Malt Liquor: On-Sale
$518.00
Consumption and Display
3.2% Malt Liquor: Off-Sale $185.00 Liquor License Transfer Only $567.00
Special Club Liquor Ask Clerk’s Office On Sale Theater $353.00
Dancing
$1130.00
2:00 A.M. (Issued by State)
Additional Bar (each) $571.00 After Hours Entertainment $262.00
TOTAL DUE:
BUSINES INFORMATION
Name of applicant (name of individual, partnership, corporation or association):
Applicant Address:
City: State: Zip:
Applicant Phone: Applicant Email Address:
Business Name/dba:
Business Address:
Business Phone:
Minnesota Tax ID Number:
Federal Tax ID Number:
List, if corporation, all stockholders, directors, officers, and percentage or number of shares owned. If partnership or
limited partnership, the name of each partner and percentage of ownership:
State approximate distance of this establishment from nearest academy, college, university, church, or school:
Who will direct the operation of the business or serve as a manager on the premises?
Full Name: Phone Number:
City of Duluth New Liquor License Application Page 2
City
M
N
Zip
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 is classified as private data and will be available to
governmental personnel and other governmental agencies whose access is necessary to perform their official duties.
BUILDING OWNER INFORMATION
Full Name:
Phone Number:
Address:
Where the building is owned by someone other than the applicant, state in summary the conditions of the
lease arrangement, such as term of lease, monthly rental, renewal privileges, etc.
DESCRIPTION OF PROPOSED BUSINESS:
What is the seating capacity of the restaurant?
Indoor Seating:
Outdoor Seating:
Designated Serving Areas (i.e. ground floor, second floor, deck, etc.)
Will serving of prepared food occur at this site?
Yes No
If yes, please attach license from MN Department of Health.
List date you desire to start serving liquor:
NOTE: The license period for a 3.2% non-intoxicating malt liquor license is May 1 to April 30. The license period for off
sale intoxicating liquor, on sale intoxicating liquor, and wine is September 1 – August 31.
Failure to answer all questions truthfully on this application and attached “Personal Supplemental Affidavit” 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 changes in ownership in this business before the change is
made, for the approval of the Alcohol, Gambling, & Tobacco Commission and City Council. I (we) have read th
e foregoing
questions, and answers to said questions are true to the best of my (our) knowledge.
I (we) will comply with all
provisions of the Alcoholic Beverage Code and the laws and regulations and their amendments.
I further understand
that the giving of false information in this application, regardless of when it is discovered, and or the failure to provide
required pertinent information constitutes cause for the immediate revocation of any and all licenses and/or
permits
issued hereunder and may be grounds for prosecution for perjury.
Signature:
Date:
Signature:
Date:
City of Duluth New Liquor License Application Page 3
Last updated 10/15/2019
PERSONAL SUPPLEMENTAL AFFIDAVIT – LIQUOR LICENSE
This form must be completed by each of the following with a copy of driver’s license or government issued ID attached:
o Applicant
o Manager(s)
o Owners, Partners, Directors, Officers, and Shareholders who own 10% or more of corporate stock unless the
company is publicly traded.
NOTE
: Type or print legibly and provide all information requested. Failure to do so may result in delay or rejection of
license applications.
1. Name of applicant (individual,
partnership, corporation or assoc.)
2. Trade Name (DBA)
3. Address of Licensed Premises
4. Business Phone
5. Individual's Cell Phone
6. Your Name (First, Middle, Last)
7. Place of Birth
(City & State, or City & Country if outside U.S.)
8. Date of Birth (MM/DD/YYYY)
9. Email
10. Home Address
11. Social Security Number (SSN)
12. Driver's License or ID Number
& Issuing State
13. L
ist your residences for the past ten (10) years – Attach additional sheets if necessary
Street Address
City
State
Zip
From
To
14. H
ave you ever been known by any other name than the one listed on this application?
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
15. A
re you an owner of this business? If so, indicate nature and percent of ownership interest:
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
16. Do you, your spouse, or your children have any pecuniary interest or own any stock in any corporation having a
pecuniary interest in the ownership, operation, management, or profits of any establishment licensed in Minnesota to sell
intoxicating liquor or 3.2% malt liquor at retail or wholesale?
Yes*
No
*If yes, state the location of the establishments involved and fully describe the nature and extent of the interest:
18. Have you or any corporation in which you held more than 10% stock, ever been denied a license to sell intoxicating
liquor, beer, wine, or 3.2% malt liquor, or had a license to sell intoxicating liquor, beer, wine, or 3.2% malt liquor
suspended or revoked?
Yes*
No
*If Yes, why?
19. Have y
ou ever forfeited bail on or been convicted of violating any law relating to gambling, prostitution, public
nuisances, possession of stolen property, assault, or the sale, distribution, manufacture, or transportation of alcoholic
beverages?
Yes*
No
*If Yes, state the violation(s), the date and location of the violation, the maximum possible penalty of the violation, and whether or not the record
of the conviction has been expunged:
20. Have your 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
DATA PRIVACY ADVISORY
The Minnesota Data Privacy Act requires that you be advised of the following information. As part of this application, you are asked to provide private and/or confidential
information about yourself that will be used to check criminal history, arrest records, warrant information, and other relevant records. You may refuse to provide this
information. However, should you refuse to provide this information, our investigation cannot be completed and will result in your application not being processed.
The information you provide will be used by the Duluth Police Department, City Clerk’s Office, the Alcohol, Gambling & Tobacco Commission, and the Duluth City
Council.
This AUTHORIZATION FOR RELEASE OF INFORMATION will expire two years from the date you signed it.
Individual __________________________________________________________________________________________
Last Name First Name Middle Name
Also known as ____________________________________________ Date of Birth: ______________________
I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.
Signature_________________________________________________Date:_____________________________
VERIFICATION
The date which you furnish on this application will be used by the City of Duluth to assess your qualifications for licensure. Disclosure
of this information is voluntary. You are not legally required to provide this data, however if you fail to do so, the City of Duluth may
be unable to process this application. Disclosure of your Social Security number (or Individual Tax ID Number only for individuals
without a Social Security number) is required by Minnesota Statutes 270C.72 and your Social Security number may be requested by
and released to the Minnesota Commissioner of Revenue. After submitting this application, all information except your Social Security
number will be public information pursuant to Minnesota Statutes, Chapter 13.
I, (print name) _________________________________________, have read and understand the above information
regarding my rights as a subject of government data. I further understand that the giving of false information as part of
this application, regardless of when it is discovered, and/or failure to give required pertinent information can constitute
cause for denial, suspension, or revocation of any and all licenses/permits and may be grounds for prosecution of perjury.
A SIGNATURE IS REQUIRED IN ORDER TO PROCESS THIS APPLICATION
Signature of applicant completing affidavit __________________________________Date_________________
Printed name of witness__________________________________ Witness Signature____________________________
Last updated 10/08/2019
PERSONAL SUPPLEMENTAL AFFIDAVIT – LIQUOR LICENSE
This form must be completed by each of the following with a copy of driver’s license or government issued ID attached:
o Applicant
o Manager(s)
o Owners, Partners, Directors, Officers, and Shareholders who own 10% or more of corporate stock unless the
company is publicly traded.
NOT
E: Type or print legibly and provide all information requested. Failure to do so may result in delay or rejection of
license applications.
1. Name of applicant (individual,
partnership, corporation or assoc.)
2. Trade Name (DBA)
3. Address of Licensed Premises
4. Business Phone
5. Individual's Cell Phone
6. Your Name (First, Middle, Last)
7. Place of Birth
(City & State, or City & Country if outside U.S.)
8. Date of Birth (MM/DD/YYYY)
9. Email
10. Home Address
11. Social Security Number (SSN)
12. Driver's License or ID Number
& Issuing State
13.
List your residences for the past ten (10) years – Attach additional sheets if necessary
Street Address
City
State
Zip
From
To
14.
Have you ever been known by any other name than the one listed on this application?
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
15.
Are you an owner of this business? If so, indicate nature and percent of ownership interest:
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
16. Do you, your spouse, or your children have any pecuniary interest or own any stock in any corporation having a
pecuniary interest in the ownership, operation, management, or profits of any establishment licensed in Minnesota to sell
intoxicating liquor or 3.2% malt liquor at retail or wholesale?
Yes*
No
*If yes, state the location of the establishments involved and fully describe the nature and extent of the interest:
18. Have you or any corporation in which you held more than 10% stock, ever been denied a license to sell intoxicating
liquor, beer, wine, or 3.2% malt liquor, or had a license to sell intoxicating liquor, beer, wine, or 3.2% malt liquor
suspended or revoked?
Yes*
No
*If Yes, why?
19. Hav
e you ever forfeited bail on or been convicted of violating any law relating to gambling, prostitution, public
nuisances, possession of stolen property, assault, or the sale, distribution, manufacture, or transportation of alcoholic
beverages?
Yes*
No
*If Yes, state the violation(s), the date and location of the violation, the maximum possible penalty of the violation, and whether or not the record
of the conviction has been expunged:
20. Have your 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
DATA PRIVACY ADVISORY
The Minnesota Data Privacy Act requires that you be advised of the following information. As part of this application, you are asked to provide private and/or confidential
information about yourself that will be used to check criminal history, arrest records, warrant information, and other relevant records. You may refuse to provide this
information. However, should you refuse to provide this information, our investigation cannot be completed and will result in your application not being processed.
The information you provide will be used by the Duluth Police Department, City Clerk’s Office, the Alcohol, Gambling & Tobacco Commission, and the Duluth City
Council.
This AUTHORIZATION FOR RELEASE OF INFORMATION will expire two years from the date you signed it.
Individual __________________________________________________________________________________________
Last Name First Name Middle Name
Also known as ____________________________________________ Date of Birth: ______________________
I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.
Signature_________________________________________________Date:_____________________________
VERIFICATION
The date which you furnish on this application will be used by the City of Duluth to assess your qualifications for licensure. Disclosure
of this information is voluntary. You are not legally required to provide this data, however if you fail to do so, the City of Duluth may
be unable to process this application. Disclosure of your Social Security number (or Individual Tax ID Number only for individuals
without a Social Security number) is required by Minnesota Statutes 270C.72 and your Social Security number may be requested by
and released to the Minnesota Commissioner of Revenue. After submitting this application, all information except your Social Security
number will be public information pursuant to Minnesota Statutes, Chapter 13.
I, (print name) _________________________________________, have read and understand the above information
regarding my rights as a subject of government data. I further understand that the giving of false information as part of
this application, regardless of when it is discovered, and/or failure to give required pertinent information can constitute
cause for denial, suspension, or revocation of any and all licenses/permits and may be grounds for prosecution of perjury.
A SIGNATURE IS REQUIRED IN ORDER TO PROCESS THIS APPLICATION
Signature of applicant completing affidavit __________________________________Date_________________
Printed name of witness__________________________________ Witness Signature____________________________
Last updated 10/15/2019
PERSONAL SUPPLEMENTAL AFFIDAVIT – LIQUOR LICENSE
This form must be completed by each of the following with a copy of driver’s license or government issued ID attached:
o Applicant
o Manager(s)
o Owners, Partners, Directors, Officers, and Shareholders who own 10% or more of corporate stock unless the
company is publicly traded.
NOTE
: Type or print legibly and provide all information requested. Failure to do so may result in delay or rejection of
license applications.
1. Name of applicant (individual,
partnership, corporation or assoc.)
2. Trade Name (DBA)
3. Address of Licensed Premises
4. Business Phone
5. Individual's Cell Phone
6. Your Name (First, Middle, Last)
7. Place of Birth
(City & State, or City & Country if outside U.S.)
8. Date of Birth (MM/DD/YYYY)
9. Email
10. Home Address
11. Social Security Number (SSN)
12. Driver's License or ID Number
& Issuing State
13. L
ist your residences for the past ten (10) years – Attach additional sheets if necessary
Street Address
City
State
Zip
From
To
14. H
ave you ever been known by any other name than the one listed on this application?
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
15. A
re you an owner of this business? If so, indicate nature and percent of ownership interest:
Yes*
No
*If yes, list all other names or aliases ever used, as well as the dates and locations (City, State/Country) of the use of each name:
16. Do you, your spouse, or your children have any pecuniary interest or own any stock in any corporation having a
pecuniary interest in the ownership, operation, management, or profits of any establishment licensed in Minnesota to sell
intoxicating liquor or 3.2% malt liquor at retail or wholesale?
Yes*
No
*If yes, state the location of the establishments involved and fully describe the nature and extent of the interest:
18. Have you or any corporation in which you held more than 10% stock, ever been denied a license to sell intoxicating
liquor, beer, wine, or 3.2% malt liquor, or had a license to sell intoxicating liquor, beer, wine, or 3.2% malt liquor
suspended or revoked?
Yes*
No
*If Yes, why?
19. Ha
ve you ever forfeited bail on or been convicted of violating any law relating to gambling, prostitution, public
nuisances, possession of stolen property, assault, or the sale, distribution, manufacture, or transportation of alcoholic
beverages?
Yes*
No
*If Yes, state the violation(s), the date and location of the violation, the maximum possible penalty of the violation, and whether or not the record
of the conviction has been expunged:
20. Have your 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
DATA PRIVACY ADVISORY
The Minnesota Data Privacy Act requires that you be advised of the following information. As part of this application, you are asked to provide private and/or confidential
information about yourself that will be used to check criminal history, arrest records, warrant information, and other relevant records. You may refuse to provide this
information. However, should you refuse to provide this information, our investigation cannot be completed and will result in your application not being processed.
The information you provide will be used by the Duluth Police Department, City Clerk’s Office, the Alcohol, Gambling & Tobacco Commission, and the Duluth City
Council.
This AUTHORIZATION FOR RELEASE OF INFORMATION will expire two years from the date you signed it.
Individual __________________________________________________________________________________________
Last Name First Name Middle Name
Also known as ____________________________________________ Date of Birth: ______________________
I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.
Signature_________________________________________________Date:_____________________________
VERIFICATION
The date which you furnish on this application will be used by the City of Duluth to assess your qualifications for licensure. Disclosure
of this information is voluntary. You are not legally required to provide this data, however if you fail to do so, the City of Duluth may
be unable to process this application. Disclosure of your Social Security number (or Individual Tax ID Number only for individuals
without a Social Security number) is required by Minnesota Statutes 270C.72 and your Social Security number may be requested by
and released to the Minnesota Commissioner of Revenue. After submitting this application, all information except your Social Security
number will be public information pursuant to Minnesota Statutes, Chapter 13.
I, (print name) _________________________________________, have read and understand the above information
regarding my rights as a subject of government data. I further understand that the giving of false information as part of
this application, regardless of when it is discovered, and/or failure to give required pertinent information can constitute
cause for denial, suspension, or revocation of any and all licenses/permits and may be grounds for prosecution of perjury.
A SIGNATURE IS REQUIRED IN ORDER TO PROCESS THIS APPLICATION
Signature of applicant completing affidavit __________________________________Date_________________
Printed name of witness__________________________________ Witness Signature____________________________
Title
Effective date
Certificate of Compliance
Minnesota Workers’ Compensation Law
This form must be completed by the business license applicant.
Print in ink or type
Minnesota Statutes § 176.182 requires 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 Minn. Stat. chapter 176. If the required information is not provided or is falsely
stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner of the Department of Labor and Industry.
A valid workers’ compensation policy must be kept in effect at all times by employers as required by law.
License or certificate number (if applicable)
N/A
Alternate telephone number
Business name (Provide the legal name of the business entity. If the business is a sole proprietor or partnership, provide the owner’s
name(s), for example John Doe, or John Doe and Jane Doe.)
DBA (“doing business as” or “also known as” an assumed name), if applicable
Business address (must be physical street address, no P.O. boxes)
City
State
ZIP code
County
Email address
You must complete number 1 or 2 below.
Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes.
1.
I have a workers’ compensation insurance policy.
Insurance company name (not the insurance agent)
Policy number Expiration date
I am self-insured for workers’ compensation. (Attach a copy of the authorization to self-insure from the Minnesota
Department of Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.)
2.
I am not required to have workers’ compensation insurance because:
I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and
messenger courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter
5224 for other industries.)
I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition
of an employee.)
I use independent contractors and I have employees who are not required to be covered by the workers’
compensation law. (Explain below.)
I only have employees who are not required to be covered by the workers’ compensation law. (Explain below.) (See
Minn. Stat. § 176.041 for a list of excluded employees.)
I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am
authorized to sign on behalf of the business.
Print name
Applicant signature (required) Date
If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or
1-800-342-5354.
LIC 04 (11/16)
Explain why your employees are not required to be covered
Business telephone number
Duluth
MN
S
t. Louis
MN STATUTE 270C.72 TAX IDENTIFICATION FORM
PURSUANT TO Minnesota Statute 270C.72, Tax Clearance Required: The licensing authority is required to
provide the Minnesota Commissioner of Revenue the business tax identification number and social security
number of each applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of
1974, we are required to advise you of the following regarding the use of this information:
1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you
owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest.
2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department
of Revenue. However, under the Federal Exchange of Information Agreement, the Department of
Revenue may supply this information to the Internal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or
re
newal application.
Please supply the following information and return along with your application to the agency issuing the
license.
License applied for or renewed:
Licensing authority: City of Duluth, St.
Louis County, Minnesota
License renewal date: N/A
Personal Information (if applicable)
Applicants Name:
Applicant’s Address:
Social Security Number:
Business Information (if applicable)
Business Name:
Business Address:
MN Tax Identification Number:
Federal Tax Identification Number:
Signature Date
CITY OF DULUTH
Duluth, MN
St. Louis
ZIP
REQUIREMENTS FOR LIQUOR LIABILITY INSURANCE CERTIFICATE
*This form is a reference document
and does not need to be submitted with
your application.
Certificate cannot be pending,
a binder, or TBA.
The Legal/Corporate name
must match EXACTLY
(word for word) to the
Approved Licensed Name
(including Inc. or LLC),
Trade Name (DBA), and
address of licensed
premises.
Legal Name and DBA here
Premises address
Minimum
s:
Personal Injury or Death:
$50,000/$100,000
Property Damage:
$10,000
Other Pecuniary Loss:
$50,000/$100,000
Loss of Means of Support:
$50,000/$100,000
Original Signature or
stamp of agent.
Last Updated 10/15/2019
Minn. Stat. 340A.409: Liquor
number must be included on
dates identical to the license
"Coverage is continuous until
be explicitly listed
Liquor Liability must
canceled."
period or must state:
certificate with coverage
Liability insurance policy
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LIQUOR LICENSE APPLICATION CHECKLIST Applicant is required to (City of Duluth)

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Completed 3 August 2020

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