2019.03.04 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 ID must be issued in the same -- — - - - - 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 of issuance V9 Over counter ❑Through vending machine ❑ Both Licensee's legal name Fed al employer ID number (FEIN) /// Business trade name (doin business as) w Daytime phone S , ` Complete address of business location (perml pcatlon) Pounty / j Other phone number city Mailing ad ess (lfdlfferent than business address) city Type of legal organization (check one): ❑ Sole proprietor ❑ Partnership ❑ Other (describe) State f Zip code I Fax number State Zip code I Email address 56 Minnesota corporation: Enter date of incorporation ❑ Out-of-state corporation: State of incorporation Are you registered to do business in Minnesota? El Yes ❑ No Corporate officers or partners (attach a list If necessary) Name A Titleb/ e Address Clay State Zip code Name Title Address city State Zip code As a licensed tobacco products or cigarette retailer, I understand that: 1. 1 can purchase cigarettes only from a Minnesota distributor or subjobber who holds a license with the Minnesota Department of �g Revenue. 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 v has a tax agreement with the State of Minnesota. a 4. 1 may not purchase from or exchange cigarettes or tobacco products with another retailer. 5. 1 must keep complete and legible cigarette and tobacco products invoices on the licensed premises, or make invoices available m 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 failure to comply with all requirements can result in criminal penalties, including the loss of cigarettes and tobacco products. 7A 4_ Licensee s�ntusre�~e Title 'oo Print name Date 5-time phone Lice Title Print name Date Daytime phone fq License applicant: Submit this form to the licensing authority along with the license application. Licensing authority: Mail or fax a copy of approved form to: Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331. (Rev. 8/12)