HomeMy WebLinkAboutItem 9 - Elmo Liquor application excerpts_Redacted 171E5T
OF
Minnesota Department of Public Safety
ALCOHOL AND GAMBLING ENFORCEMENT DIVISION i.
444 Cedar St.,Suite 222,St.Paul,MN 55101-5133 3�+ins d
''�UF N�NNE
(651)201-7507 FAX(651)297-5259 TTY(651)282-6555
W W W.DPS.STATE..MN.US
APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
No license will be approved or released until the$2 Retailer ID Card fee is received
Workers compensation insurance company.Name K Policy# UD( N 21 93a`i�
Licensee's MN Sales and Use Tax ID# 3 A 3 5 1 3 Z To apply jw•a AM sales and use tax ID#,call(651)296-6181
Licensee's Federal Tax ID# L4 3 - 9_1-Io 5:1 57
If a corporation,an officer shall execute this application If a partnership,a partner shall execute this application.
Licensee Name(Individual,Corporation,Partnership, LLC) Social Security# Trade Name or DBA
I
G r1 I ma L'i Yt
License Location(Street Address&Block No.) License Period Applicant's Home Phone#
Z 1 uts From,3..I'k 15 To,De c.
City County State Zip Code
L a e Elm Wo 1\-,LN40 r An a5 a 4
Name of Store Manager Business Phone Number DOB(Individual Applicant)
1: .. k 6 2-- 19, 3
If a corporation or LLC state name,date of birth,Social Security#address,title,and shares held by each officer. If a partnership,state
names,address and date of birth of each partner.
Partner Officer(First,middle,last) DOB SS# Title Shares Address,City,State,Zip Code
Cadsao,
Partner Officer(First,middle,last) DOB SS# Title Shares Address,City,State,Zip Code
SG Q Io �Dc� W97 To;do,n C,�-ae
0
Partner Officer(First,middle,last) DOB SS# Title Shares Address,City,State,Zip Code
Partner Officer(First,middle,last) DOB SS# Title Shares Address,City,State,Zip Code
l. If a corporation,date of incorporation 12.S l 1-1 state incorporated in Ph% nge so 6A ,amount paid in
capital .$60,000"' . If a subsidiary of any other corporation,so state and give purpose of
corporation . If incorporated under the laws of another state,is corporation
authorized to do business in the state of Minnesota? I Yes No
?. Describe premise to which license applies; such as(fir t floor,second floo ,basement,etc.)or if entire building,so state.
a. 5 `
3. Is establishment located ne •any state university,state hospital,training school, reformatory or prison? .:Yes No f yes state
approximate distance.
4. Name and address of building owner: Vte40.InG 1&0 vim. 16u, 5401,6
a r j 9 63 0 Walejea 3,—
Has owner of building any connection,directly or n1directly,with applic t. es No
5. Is applicant or any of the associates in this application.a member of the governing ody of the municipality in which this license is
to be issued? 7 Yes Q(TIo If yes,in what capacity?
6. State whether any person other than applicants has any right,title or interest in the furniture,fixtures or equipment for which license
is applied and if so,give name and details. N
7. Have applicants any interest whatsoever,directly or indirectly,in any ther liquor establishment in the state of Minnesota?
Yes No If yes,give name and address of establishment.
S. Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business
establishment? KYes .No
9. State whether applicant has or will be granted,an On sale Liquor License in conjunction with this Off Sale Liquor License and for
the same premises. :.!Yes I-No i__Will be granted
10. State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor
License. ❑Yes kNo ❑Will be granted
11. If this application is for a County Board Off Sale License,state the distance in miles to the nearest municipality.
12. State Number of Employees 3
13. If this license is being issued by a County Board, has a public hearing been held as per MN Statute 340A.405 sub2(d)?
14. If this license is being issued by a County Board,is it located in an organized township? If so,attach township approval.
1. State whether applicant or any of the associates in this application, (have ever had an application for a liquor license rejected by any
municipality or state authority; if so,give dates and details. N
2. Has the applicant or any of the associates in this application,during the five years immediately preceding this application ever had a
license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so,give dates and
details. M, t>
3. Has applicant,partners,officers,or employees ever had any liquor law violations or felony convictions in Minnesota or
elsewhere,including State Liquor Control penalties? Yes KNo If yes,give dates,charges and final outcome.
!. During the past license year,has a summons been issued under the Liquor Civil Liability Law(Dram Shop)M.S.340A.802.
Yes ( No If yes,attach a copy of the summons.
This licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.)
Check one
A. Liquor Liability Insurance(Dram Shop)-$50,000 per person,$100,000 more than one person; $10,000 property
destruction; $50,000 and$100.000 for loss of means of support.
or
J B. A surety bond from a surety company with minimum coverage as specified in A.
or
❑ C. A certificate from the State Treasurer that the licensee has deposited with the state,trust funds having market value of
$100,000 or$100,000 in cash or securities.
certify ahave read e above ues ions an a TM answers are true and correct of my own 1inow e ge.
Print name ot applicant&title Signature of Applicant Date
REPORT BY POLICEISHERIFF'S DEPARTMENT
This is to certify that the applicant and the associates named herein have not been convicted within the past five years for any violation of
laws of the State of Minnesota or municipal ordinances relating to intoxicating liquor except as follows:
Police/Sheriffs Department I itle Signature
PS 9136-(2009)
County Attorney's Signature
IMPORTANT NOTICE
All retail liquor licensees must register with the Alcohol,Tobacco Tax and Trade Bureau.
For information call(513)684-2979 or 1-800-937-8864
City of Lake Elmo
3800 Laverne Avenue North
Lake Elmo,MN 55042
APPLICATION FOR ON SALE LIQUOR LICENSE and/or
WINE LICENSE and/or
WINE LICENSE PLUS A 3.2% MALT LIQUOR LICENSE (TO SELL STRONG BEER)
FOR A RESTAURANT and/or
OFF-SALE INTOXICATING LICENSE/OFF-SALE 3.2 %LICENSE
This application/renewal shall be completed and filed with the City Clerk together with the appropriate forms and
proof of liability insurance as required by State Statute and City Code. Every question must be answered. The
applicant shall be stated in the same manner for this application form, on all related forms and on the certificate of
insurance.
Applicant Name Eimp Liquor y1 c,
(Individual,Bus& ess, Partnership,Corporation)
Applicant Name
(Individual,Business, Partnership,Corporation)
Trade Name or Doing Business As e 11'l_L, hquw I riC
Business Address 1 1 c7 � (� ` ,�� �! L4 e Jrnub AN Ss Ll �-
city State Zip
Applicant is: Owner Operator
License period: January Ito December 31, aZ��; or Other
Age of applicant: j + Is the applicant a citizen of the United States?
Application is: -New Renewal
Name of former owner(if applicable) N /_4N
How long has the applicant been in this business at this address? jp( c AA�S 0,ve—
i 1
If partnership, state the name and address of each partner. If corporation, state the name and
address of each officer:
SNNN )ANTTA2 WV 30113-av%, CIN-1 LcA6y-A Mm 5SoLui
Busi ess Partner/Officer Address
P�1�k L Carlson, I62G 14uK:�r L-9r2J 0uison tc� I
Business Partner/Officer Address
Business Partner/Officer Address I I n II I
The owner of the property is: ruo JflS(e4 1P l,�'�� 0. Ca ��yl. + 1' i
The address of the property owner is: L 6 /�630 ltj,
,3L �j ul)
Does the building owner have connections, direct or indirect, with the applicant?
Are the property taxes delinquent? _yes X no
Pak As_5-jyrej(See.�
Describe the premises to be licensed Lot Number Block Number
• Please attach a floor plan of licensed premises (including patio if applicable)
Restaurant
Seating Capacity Business Hours Hours food will be available
Number of Employees Seasonal Operation yes no
Will food be the principal business of the restaurant? yes no
What percentage of business is food %. If no, describe the principal business:
License being applied for with this application: On Sale Liquor$1,500 (2"d $750)
(Please note the combination of On-Sale On Sale Wine $300
Wine & 3.2%allows for the sale of strong beer) On Sale 3.2 Malt Liquor $100
On-Sale Club $100
On-Sale Sunday $200
Off-Sale Liquor $200
Off-Sale 3.2 Malt Liquor$150
New Licensee Investigation: Investigation Fee $350
• New Licensees must submit investigation forms and applicable fees for all
owners/managers.
• Upon renewal the city council may determine to conduct a background investigation on
any license holder within the city limits and the licensee will be responsible for the
investigation fee.
Is the applicant, or any of the associates in this application a member of the Lake Elmo City
Council?^yes_'�< _no (If the applicant is the spouse of a member of the City Council, or another family
relationship exists,the member shall not vote on this application.)
During the past year has a summons been issued under the liquor civil liability law, also know as
the dram shop law?des_'�_no If yes, attach a copy of the summons.
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? If yes, give
details and dates:
Does the applicant have any interest, directly or indirectly, in any other liquor establishment in
Minnesota?_yes_-X_no If yes, provide name and address of the establishment:
Please attach to this application:
A. 74-Certificate of Insurance-$50,000 per person; $100,000 more than one
person; $10,000 property destruction; $50,000 and $100,000 for loss of
means of support, and
B. A surety bond in the amount of$1000, or in lieu of a bond, cash or United States
government bonds of equivalent value.
C. Proof of Financial Responsibility: No liquor license may be issued, maintained, or
renewed unless the applicant demonstrates proof of financial responsibility with
regard to liability imposed by M.S. 340A.801. The proof shall be filed with the
Commissioner and the liability insurance policy shall conform to M.S. 340A.409.
Have you presented a check in full payment of the license fee(s) made payable to the City of
Lake Elmo and the investigation fee included if applicable? es no/provide reason:
(no license will be processed without proper payment)
You have submitted a check for $20 made payable to AGED for a buyers card and submitted it
directly to the Director of Public Safety, Alcohol and Gambling Enforcement Division, 444
Cedar Street, Suite 222, St. Paul, MN 55101 (applicable to all on-sale liquor and wine licenses
and off-sale liquor licenses (not 3.2 malt liquor)dyes no/not applicable.
I CERTIFY THAT I HAVE READ THE ABOVE QUESTIONS AND THAT THE
ANSWERS ARE TRUE AND CORRECT.
Signature of Applicant Date
Signature of Applicant Date
REPORT BY WASHINGTON COUNTY SHERIFF DEPARTMENT
This is to certify that the applicant(s), and the associates, named herein have not been convicted
within the past five years for any violation of Laws of the State of Minnesota, Municipal or
Co un ordin%e, elatin to intoxicating liquor:C� : G.�/J
zA 62.
i�
Sheriff ignature Title Date
This is to certify that the applicant(s), and/or the associates, named herein have the following
conviction(s)/violation(s) on record within the past five years pursuant to the Laws of the State of
Minnesota, Municipal or County ordinances relating to intoxicating liquor:
Sheriff Signature Title Date
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