Business Trade Name Business Address. City Zip Code County _Beltrami_ Township Business Ph

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1 Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 444 Cedar Street, Suite 133, St. Paul, MN Telephone Fax TTY Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday Liquor License Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor license types: 1) City issued on sale intoxicating and Sunday liquor licenses 2) City and County issued 3.2% on and off sale malt liquor licenses Name of City or County Issuing Liquor License _Beltrami_ License Period From: To: Circle One: New License License Transfer Suspension Revocation Cancel (former licensee name) (Give dates) License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale 3.2% Off Sale Fee(s): On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ Licensee Name: DOB Social Security Circle one (corporation, partnership, LLC, or Individual) Business Trade Name Business Address City Zip Code County _Beltrami_ Township Business Ph Home Address City Home Ph Licensee s MN Tax ID # (To Apply call ) (To apply call IRS ) Licensee s Federal Tax ID # If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: Spouse/Partner/Officer Name (First Middle Last) DOB Social Security # Home Address (Partner/Officer Name (First Middle Last) DOB Social Security # Home Address Partner/Officer Name (First Middle Last) DOB Social Security # Home Address Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must contain all of the following: 1) Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. 2) Cover completely the license period set by the local city or county licensing authority as shown on the license. Circle One: (Yes No) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? Workers Compensation Insurance is also required by all licensees: Please complete the following: Workers Compensation Insurance Company Name: Policy # Dates of Coverage I certify that this license(s) has been approved in an official meeting by the governing body of the county. County Auditor-Treasurer Signature Date

2 Describe premises to which license applies, another words where liquor will be allowed, be specific (first floor, entire bldg, patio etc ). Does the applicant or any immediate family member of applicant (spouse, parents, siblings, or descendants) have a five percent or more interest in any other liquor establishment in Beltrami County? Have applicants ever engaged in a similar business and, if so, give location and the date when so engaged? Give a complete and detailed description of the nature of the business operation to be conducted on the premises. If this business is a corporation, please give the date of incorporation, state incorporated in. List all persons with interest in the corporation and their extent of interest include shareholders, showing the number of shares held by each. Is there anyone with financial interest in the business other than an owner, director, partner or resident manager? _ I said owner/president state that this establishment will not be open or serving after 1:00 am. Owner s/president s Signature: Date Physical address of business Corporation/principle office address if different Remember that the Federal Special Occupational Tax also needs to be kept current. You may contact the Federal Bureau of Alcohol with questions or concerns about this matter ******************************************************************************************* **To be filled out by appropriate county department. I am NOT aware of any violations of statute 340A.412 Sub 2 or other criminal conduct that would render the applicant ineligible to apply for this license. I AM aware of statutory violations and/or other criminal conduct that which renders the applicant ineligible to apply for this license. Signed: Beltrami County Sheriff Date Indicate investigation cost over and above $ fee I am NOT aware of any violations of statute 340A.412 Sub 2 or other criminal conduct that would render the applicant ineligible to apply for this license. I AM aware of statutory violations and/or other criminal conduct that which renders the applicant ineligible to apply for this license. Signed: Beltrami County Attorney Date

3 Business Location Map Please provide a map showing the exact location of the property. Show the location where the building structure is located and a complete site plan including the dimensions of the lot and location of the building on the lot, the location and dimensions of all parking facilities, lighting for the parking area, details to the entrance and exits to the site from existing roadways, entrances and exits from the building to the parking lot areas, size and location of all signs, and a complete and detailed floor plan of the building. Real estate tax parcel#

4 TOWNSHIP CONSENT FORM OWNER: D B A: ADDRESS: TYPE OF LICENSE(S): STATE OF MINNESOTA) (SS COUNTY OF BELTRAMI) TOWN OF: IT IS HEREBY CERTIFIED THAT THE TOWN BOARD OF: IN SAID COUNTY AND STATE, BY RESOLUTION ON THE DAY OF, 20 DID CONSENT TO THE ISSUANCE OF THE ABOVE LICENSE, FOR STATED OWNER AND BUSINESS. DATED, 20 THE TOWN BOARD OF: ATTEST: CLERK BY: CHAIRMAN PLEASE RETURN SIGNED FORM TO: BELTRAMI COUNTY AUDITOR/TREASURER ATTN: JODEE TREAT 701 MINNESOTA AVE NW #220 BEMIDJI, MN

5 BELTRAMI COUNTY AUDITOR/TREASURER S OFFICE JoDee Treat 701 Minnesota Ave NW 220 Bemidji, MN ; Fax License Application Supplement Applicant Information: Name: / / Last First Middle Home Address: City/State/Zip List any previous out of state address/es you have had Are you currently a resident of Beltrami County? (If no please see Section V, (h) of the liquor ordinance) Hm Ph #: Bus Ph # D.O.B. / / Driver s Lic# Age Place of Birth Give a complete list of any convictions whether alcohol related or not. Type of License/s Applying for: Business Name: Business Address: Your Title: manager, director, principal operator or Agent affect voting control please see Sec V, b, 11 of liquor ordinance) To be filled out by each owner, partner, officer, (The county must be notified of any change of ownership that would

6 CERTIFICATION OF COMPLIANCE MINNESOTA WORKERS COMPENSATION LAW Minnesota Statute, Section 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 is: the name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and retained in their files. Law requires this information, 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: Policy Number: Dates of Coverage: to MUST PROVIDE CERTIFICATE OF INSURANCE 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 Or ********* I certify that the information provided above is accurate and complete and if required a valid compensation policy will be kept in effect at all times as required by law. workers Name: Doing Business As: Signature: Business Address: Phone: Date:

7 BELTRAMI COUNTY AUDITOR/TREASURER S OFFICE I,, LICENSED TO SELL Please print name ON SALE AND/OR OFF SALE 3.2 PERCENT BEER HAVE NOT IN THE PAST YEAR & DO NOT EXPECT TO IN THE CURRENT YEAR, SELL OVER $25, IN 3.2 PERCENT BEER SALES AND AM NOT REQUIRED TO CARRY DRAM SHOP INSURANCE: OR HAVE DRAM SHOP INSURANCE: (PLEASE CHECK) DATE SIGNATURE DBA NOTARY SIGNATURE DATE