2016.01.04 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 The Minnesota tax ID must be issued in the same -3l� , _W ( legal name of the licensee below. Cigarettes/tobacco products (will be sold (a separate license is required foreach location or vending machine): L�/2FKver counter ❑Through vending machine EJ Both FOR MUNICIPAL USE ONLY F e number covered f issuance ucensee s legal am/etco rr Fed r I eme r.lp nberumNye Business trade name (doing business as) Daytime phone Complete addie55 of business location (permit location}„ County Jgg Other phone number City S Zip code Fax number Mallin a ess.(iftliflerentthanbusssatltlress) ;7 Cityq. ,/State Zip code Email address Type of legal organization (check one): Ll Sole proprietor ❑Partnership �� E) Other (describe) 05a' -Ey ❑ Minnesota corporation: Enter date of incorporation ❑ Out-of-state corporation: State of incorporation _ IN Are you registered to do business in Minnesota? Dyes ❑ No Corporate officers or partners (attach a list if necessary) ws a ucensee ioaacco proaucis 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 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 has a tax agreement with the State of Minnesota. 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 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, includingthe loss of cigarettes and tobacco products. Lic ng s gnatureTitle 1 Print n�ame(,t U y-/ Date " \Daytime phone Licensing agent's signature W Titif � !�1'na'Print name a�.1`^ ate `iUl Date Daytime phone 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: Hugo City Hall, 14669 Fitzgerald Ave. N., Hugo, MN 55038 eer.. 8/12)