2017.04.17 CC Packet - Laserfiche WebLink

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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. Applicant's Minnesota tax ID number FOR MUNICIPAL USE ONLY The Minnesota tax !D must be Issued in the same 37 Z 96 legal name of the licensee below. License number Period covered Cigarettes/tobacco products will be sold (a separate license is required for each location or vending machine). Date or issuer ce Over counter t Through vending machine (J Both Lirensee's legat name Business trade name (do ng business ) f Complete addrese of business br it�nn 1permR location) tit} /-c uo M N Mailing aO4:s if difrererrt than business adr"i•eas) city Type of legal organization (check one); L' Sole proprietor Partnership 0 Other (describe) Federal empMyer iD number tFEINI L_./0 > 3 Daytime piw e yy?-Z&G-tJd6� outer phone number —c��-nde -- State 6-5-03 8 raxnumber A6o --z -- �StateT Zip rode ' Emad address Minnesota corporation: Enter date of incorporation Z Out-of-state corporation- State of incorporation /�, Are you registered to do business in Minnesota? ! Yes No Corporate officers or partners (attach a list if necessary;) Name L Titlesrl 1 Ulu rG' !Z 1, e, c A q �rr2 s i e ,-1 1 Address T r_qy State Zip code _ 6 1 g I F�}� ,, j ,)r H u Mti S-i::' 3 Name Title Address r State 7in, As a licensed tobacco products or cigarette retailer, l understand that: 1. 1 can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of Revenue. 0 2. 1 must obtain a tobacco products distributor license if I purchase untaxed tobacco products from an out-of-state company. n 3. 1 may not sell cigarettes affixed with Minnesota Native American stamps unless my retail business is located on a reservation that s has a tax agreement with the State of Minnesota. 1 4. 1 may not purchase from or exchange cigarettes or tobacco products with another retailer. 0 5. 1 must keep complete and legible cigarette and tobacco products invoices on the licensed premises. or make invoices available Y within one hour of request. for at least one year after the date of the purchase. 6. 1 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. 1 know that tailwe to t romply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco products. ag Licensee signature Title Print name Date Daytime phone 0 IA?V1 f iC jer )V-v;kc,t1—_ /3 -17 Y S-2 - 206- -OS6 5 F Licensingawrs si aturc Title Print name Date -- Daytime ohoec nl r License applicant: Submit this form to the licensing authority along with the license application. Licensing autthorfty: Mail or fax a copy of approved form to: Minnesota Revenue. Mail Station 3331. St. Paul, MN 55146-3331.