Fillable TobaccoLicense2019Fillable City of Farmington

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TobaccoLicense2019Fillable City of Farmington

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CITY OF FARMINGTON
LICENSE PROCESS
Tobacco License
A tobacco license is required to regulate the sale of all tobacco products. Please review Title 3 Chapter 7 of
the city code for complete details. All licenses expire December 31 of each year. Following is the process
to obtain a tobacco license:
1. Application forms and fees should be submitted to the city of Farmington at least two weeks prior to
a City Council meeting.
2. A background check will be performed by the Farmington Police Department.
3. Approval is required by the City Council. Council meetings are held the first and third Mondays of
every month.
4. Upon City Council approval, a license is issued. The entire application process takes approximately
two weeks.
5. Fees: $200/year
If you have questions, please contact:
Cynthia Muller, Administrative Assistant
City of Farmington
430 Third Street
Farmington, MN 55024
Tel: 651-280-6803
E-mail: CMuller@FarmingtonMN.gov
Checklist for Tobacco 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. Tobacco License Application (Form TLIC2009) ____________ ____________
2. State form CT102 __________ __________
2. All applicable Fees (See fee schedule below) ____________ ____________
3. Copy of City Tobacco Sales Regulations __________ ___N/A____
License Fees
Cigarette / Tobacco Sales $200
(New or Renewal)
Reinstatement after Revocation $150 (plus Administrative Time per fee schedule)
Application for Tobacco License
(Form TLIC2009)
APPLICANT INFORMATION
Applicant Name: ________________________________________Title: ___________________________
(First) (Middle) (Last)
Applicant Address: _____________________________________________________________________
(Street) (City, State, ZIP)
Applicant Home Phone: _______________________________ Date of Birth: _______________________
BUSINESS INFORMATION
Business Name:________________________________________________________________________
Address:______________________________________________________________________________
(Street) (City, State, ZIP)
Business Phone: __________________ FAX:___________________ Email: _______________________
Business Type: Proprietorship ____ Partnership _____ Corporation_____ LLC _____
Type of Cigarette Sales: Vending Machine _____ Display / Counter_____
I hereby certify that all statements made in this application are true and complete to the
best of my knowledge. I understand that any misstatements or omissions of material facts
may result in the disqualification or denial of the license. I authorize the City of Farmington
to investigate the information and contact persons/organizations named on this
application.
Name of Applicant (please print) ___________________________________________________
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_____________________ __________ _____________________________
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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
MINNESOTA REVENUE CT102
License Application to Make Retail Sales of Cigarette and Other Tobacco Products
To be completed by applicant when applying for a license with a city or county.
For Municipal Use Only
The Minnesota tax ID must be issued in the
same legal name of the licensee below.
Cigarettes/tobacco products will be sold (a separate license is required
for each location or vending machine):
____ Over Counter ______ Through vending machine ______ Both
Licensee’s legal name
Federal employer ID number (FEIN)
Business trade name (doing business as)
Daytime phone
Complete address of business location (permit location) County
Other phone number
City State Zip code
Fax number
Mailing address (if different than business address) City State Zip code
Email address
Type of legal organization (check one):
___ Sole proprietor _____ Minnesota corporation: Enter date of incorporation__________
___ Partnership ____ Out-of-state corporation: State of incorporation______________
___ Other (describe) ____________ Are you registered to do business in Minnesota? ___ Yes ___ No
Corporate officers or partners (attach a list if necessary)
Name Title
_______________________________________________________________________________________
Address City State Zip code
_______________________________________________________________________________________
Name Title
_______________________________________________________________________________________
Address City State Zip code
_______________________________________________________________________________________
As a licensed tobacco products or cigarette retailer, I understand that:
1. I can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of Revenue.
2. I must obtain a tobacco products distributor license if I purchase untaxed tobacco products from an out-of-state company.
3. I may not sell cigarettes affixed with Minnesota Native American stamps unless my retail business is located on a reservation that has a tax
agreement with the State of Minnesota.
4. I may not purchase from or exchange cigarettes or tobacco products with another retailer.
5. I must keep complete and legible cigarette and tobacco products invoices on the licensed premises, or make invoices available within one
hour of request, for at least one year after the date of the purchase.
6. I know that the Minnesota Department of Revenue and/or law enforcement may conduct cigarette and tobacco inspections of the premises,
including inspections of inventory, invoices and licenses, and I understand that a refusal to allow an inspection is grounds for revocation of
my license.
7. I know that failure to comply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco products.
Licensee signature Title Print Name Date Daytime phone
______________________________________________________________________________________
Licensing agents signature Title Print Name Date Daytime phone
_____________________________________________________________________________________
License applicant: Submit this form to the licensing authority along with the license application.
Licensing authority: Mail or fax a copy of approved form to:
Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331. Fax 651-297-1939 Phone: 651-297-1882. TTY: Call 711 for MN Relay.
Applicant’s Minnesota tax ID number
License Number
Period Covered
Date of Issuance
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Completed 12 July 2020

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