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DEPARTMENT CT102 OF REVENUE 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 Applicant's Minnesota Tax ID Number The Minnesota Tax ID must be issued in the same License Authority 7 7 !� �. legal name of the licensee below. License Number Clgarettes/tobacco products will be sold(a separate license is required Period Covered for each location or vending machine): 01 Yover Counter ❑Through Vending Machine ❑Both Date of Issuance Licensee's Legal Name Federal Employer ID Number(FEIN) -56 VrA-0 c - Y1111 4ez Business Trade Name(doing business as) Daytime Phone 3 0 o jZrxcs - 7rsS Complete Address of Business Location(permit location) County Other Phone Number City State ZIP Code Fax Number 1 'L- _ _ _ c - 7 7'/- a Mailing Address(!f different than business address) City State ZIP Code mall Adfiress _ ■ r l,i(`' / Type of legal organization(check one): Sale proprietor ot+ke ❑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 - I Corporate officers or partners(attach a list if necessary) 151 U Lt! Name Title --)AN IJI.CTkI?IL `�.t2o�R/lD�� ---- Address City p State ZIP Code 14 Name Title Address City State ZIP Code As a licensed tobacco products or cigarette retailer,I understand that: 1. 1 can purchase cigarettes and tobacco from a Minnesota distributor or subjobber who holds a license with the Minnesota Department quo of Revenue.The Cigarette and Tobacco Distributor List is on our website. Go to www.revenue,state.mn.us and type Distributor List In the Search box. 2. 1 must obtain a tobacco products distributor license if I purchase untaxed tobacco products from an out-of-state company. 3. 1 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. 16 4. 1 may not purchase from or exchange cigarettes or tobacco products with another retailer. d5. 1 must keep complete and legible cigarette and tobacco products invoices on the licensed premises,or make invoices available within one hour of request,forat-Ieast of a year after the date of the purchase. 6. 1 know that the M�eie ota Dep ment of Revenue and/or law enforcement may conduct cigarette and tobacco inspections of the premises,includjng Inspecti 7 of inventory,invoices and licenses,and I understand that a refusal to allow an inspection is grounds for revocation of rriy license. 7. 1 know that fillure to cttirinply with all requirements can result in criminal penalties,including the loss of cigarettes and tobacco products, Licensee SEgnatur. Title Print Name Date Daytime Phone aw,cr � s+b dr J �' r► r�r i 3 /a.<f-276 7a Licensing Agent's Signature Title Print Name oat — Daytime Phone License applicant:Submit this form to the licensing authority along with the license application. Licensing authority:Mail,email or fax to: Minnesota Revenue,Mail Station 3331,St.Paul,MN 55146-3331. Fax:651-556-5236. Email:cigarette.tobacco@state.mn.us (Rev.7/19)