Application For Consumption And Display Permit

APPLICATION FOR CONSUMPTION AND DISPLAY (Set Up) PERMIT PEMIT FEE $250 (Permits expire March 31st of each year) To apply for MN Tax ID# 651-296-6181A $30.00 service charge will be added to all dishonored checks. You may also be subjected civil penalty of $100 or 100% of the value of the check, whichever is greater, plus interest and attorney fees. Applicants Full Name (Business, Partnership, LLC, Corporation) DOB SS# Trade Name or DBA Business Street Address County Business Phone City State Zip Code Permit Type Private Club Public Business Type of Business (Restaurant, Dance Hall, etc.) Full Name of Business or Club Manager DOB Address of Manager Name of Building Owner Address of Owner Are the club or business premises separate from any other business establishment? Yes No Is there a current 3.2 beer license to this business at this location? Is application Yes No Original Transfer If transfer, former license and business trade name If a partnership, state the name and address of each partner. If a corporation, state the name and address of each officer. If a club, state the name and address of each officer or director. Full Name DOB SS# Address Full Name DOB SS# Address Full Name DOB SS# Address For a Private club. A club must attach a copy of the constitution and bylaws of the club and current list of members. Date club organized Number of members Amount of dues Membership requirements Is club owned or rented? Length of time club at present location Does club store liquor for members? Yes No Has applicant; if partnership, any partner; if corporation, any officer or director; if club, any club officer or director, ever had a license under the Minnesota Liquor Control Act revoked or suspended or been convicted for any violation of State laws or local ordinances; if so, give date and details. I hereby certify that the answers are true of my own knowledge and understand that the giving of false information or the failure to give pertinent information constitutes cause for revocation of this permit. THIS PERMIT DOES NOT ALLOW THE SALE OF INTOXICATING LIQUOR. Permittee SignatureDate(Signature certifies all above information to be correct and permit has been approved by city/county.) City/County Auditor SignatureDate(Signature certifies all above information to be correct and permit has been approved by city/county.) Amount Received