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ANOKA COUNTY Property Records & Taxation, Vital Records 2100 3rd Ave N, Suite 119, Anoka MN 55303 TEL: [PHONE REDACTED] FAX: [PHONE REDACTED] Combination Application for Retailer’s 3.2 Malt Liquor License On-sale Off-sale EVERY QUESTION MUST BE ANSWERED. If a corporation, an officer shall execute this application. If a partnership, a partner shall execute this application. Licensee’s Sales & Use Tax ID # To apply for MN sales tax number call [PHONE REDACTED] Licensee’s Federal Tax ID # Applicant’s name (Business, Partnership, LLC, Corporation) DOB Social Sec # DBA or trade name License address Business phone Applicant’s home phone City County State Zip code Is this application New Renewal Transfer If a transfer, give name of former owner Licensed period (7/1 to 6/30 annually) From To Give full name, residence, DOB, Social Security title and age for all partners, or the officers and directors of a partnership or corporation, and the percent of stock held by each officer if applicable. Name Social Sec # Title DOB Address City, State Zip code Name Social Sec # Title DOB Address City, State Zip code Name Social Sec # Title DOB Address City, State Zip code CORPORATIONS Date of incorporation State of incorporation Certificate Number Is corporation authorized to do business in Minnesota? YES NO Purpose of corporation If a subsidiary of another corporation, give name and address of Parent Corporation BUILDING AND RESTAURANT Name of building owner Owner’s address Are Property Taxes delinquent? YES NO Has the building owner any connection, direct or indirect, with the applicant? YES NO Restaurant seating capacity Hour’s food will be avail. No. of people restaurant employs No. of months per year restaurant will be open Will food service be the principle business YES NO Describe the premises to be licensed If the restaurant is in conjunction with another business (resort, etc.), describe business OTHER INFORMATION 1. Is the applicant or any of the associates in this application a member of the county board or the township board, which will issue this license? YES NO 2. During the past license year has a summons been issued under the liquor civil liability (Dram Shop) (M.S. 340A802). YES NO If yes, attach a copy of the summons. ---PAGE BREAK--- 3. Has the applicant or any of the associates in this application been convicted during the past five years of any violation of federal, state or local liquor laws in this state or any other state? YES NO If yes, give date and details. 4. Does any person other than the applicants, have any right, title or interest in the furniture, fixtures or equipment in the licensed premises? YES NO If yes, give names and details. 5. Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? YES NO If yes, give name and address of the establishment. I will comply strictly with the provisions of the ordinance relating to the sale of soft drinks for “mixing” purposes and will serve patrons in full view of the public. I agree to waive my Constitutional Rights against search and seizure and will freely permit peace officers to inspect my premises and agree to the forfeiture of my license if found to have violated the provisions of the ordinance (resolution) providing for the granting of this license. I hereby solemnly swear that the foregoing statements are true and correct to the best of my knowledge and that I agree to comply with all the provisions of the ordinance under which this license is granted. Subscribed and sworn to before me this Signature of Applicant day of Public Notary The Licensee must have one of the following: CHECK ONE ⃞ A. Liquor Liability Insurance (Dram Shop) - at a minimum $300,000 per person; $300,000 more than one person; $300,000 property destruction; $300,000 for loss of means of support. ATTACH “CERTIFICATE OF INSURANCE” TO THIS FORM. Or ⃞ B. A Surety bond from a surety company with minimum coverage’s as specified above in A. Or ⃞ C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a market value of $300,000 or $300,000 in cash or securities. REPORT BY ANOKA COUNTY ATTORNEY’S DEPARTMENT I certify that to the best of my knowledge the applicants named above are eligible to be licensed. ⃞ YES ⃞ NO If no, state reason. Signature County Attorney Title Date REPORT BY ANOKA COUNTY SHERIFF’S DEPARTMENT I certify that to the best of my knowledge, the applicants named above have not been convicted within the last five years for any violations of Sate Law or municipal ordinance relating to the sale of liquor, except as follows: Signature Sheriff Title Date APPROVAL BY TOWN BOARD It is hereby certified that the Town Board of in Anoka County, MN by resolution on the day of did consent to the issuance of the license applied for in the within application. Town Board approval attached if not signed below. Chairman Town Clerk Date IMPORTANT NOTICE No County Board shall issue license for sale in any Town without the consent of the Town Board of such Town, and no Town Board shall consent to the issuance of any license without the written recommendation of the County Attorney and the Sheriff. ALL RETAIL LIQUOR LICENSEES MUST HAVE A CURRENT FEDERAL SPECIAL OCCUPATIONAL STAMP. THE BUREAU OF ALCOHOL, TOBACCO AND FIREMARMS ISSUES THIS STAMP. FOR INFORMATION CALL [PHONE REDACTED].