Fillable CITY OF DULUTH LICENSE APPLICATION CITY CLERKS OFFICE (City of Duluth)

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CITY OF DULUTH LICENSE APPLICATION CITY CLERKS OFFICE (City of Duluth)

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CITY OF DULUTH
CITY CLERK’S OFFICE
330 City Hall
411 West First Street
Duluth, Minnesota 55802-1189
Phone (218) 730-5500
Fax (218) 730-5923
LICENSE APPLICATION
LICENSE TOTAL FEE
1 Day Temporary Consumption &
Display Permit
$ 25.00
LICENSEE NAME/ADDRESS/PHONE NO.
__________________________________________
__________________________________________
__________________________________________
__________________________________________
CONTACT’S NAME/ADDR/PHONE NO.
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Email Address:______________________________
OWNER OF BUSINESS PREMISES:
_____________________________________________
_________________________________________
___________________________________________
DATE OF EVENT:___________________________
IS LICENSEE A NON-PROFIT ORGANIZATION?
YES NO
Please note: There are only 10 One Day
Consumption and Display Permits issued per year
and they are processed on a first come, first served
basis.
I HEREBY STATE THAT ALL INFORMATION HERE IS TRUE AND CORRECT AND THAT I SHALL COMPLY WITH ALL
PROVISION 0F THE ORDINANCES OF THE CITY OF DULUTH AND LAWS OF THE STATE OF MINNESOTA AND THEIR
AMENDMENTS.
__
_____________________________________________
Signature of Applicant
MAI
LING ADDRESS (If different than licensee):
__________
___________________________
_____________________________________
_____________________________________
_____________________________________
FOR OFFICE USE ONLY
DATE_________________
LICENSE #_____________
GOVERNMENT DATA PRACTICE
S ACT - CLASSIFICATION WARNING
The data you supply on this form will be used to process the license you are applying for. You are not legally required to provide this data,
but we will not be able to process the license without it. Some of the data will be classified as public data if and when the license is
granted. Private financial information including a tax identification number and social security number are classified as private data and
will be available to governmental personnel and other governmental agencies whose access is necessary to perform their official duties.
Minnesota Department of Public Safety
Alcohol and Gambling Enforcement Division
445 Minnesota Street, Suite 222, St. Paul, MN 55101
651-201-7500 Fax 651-297-5259 TTY 651-282-6555
APPLICATION AND PERMIT FOR A 1 DAY
TEMPORARY CONSUMPTION AND DISPLAY PERMIT
(City or county may not issue more than 10 permits in any one year)
Name of organization Date organized
Tax exempt number
Address
City
State
Zip Code
Name of person making application Business phone
Home phone
Dat
e(s) of event
Type of organization
Club
Charitable
Religious
Other non-profit
Organization officer's name City State Zip
Loc
ation where permit will be used. If an outdoor area, describe.
APPROVAL
APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT
City or County approving the license Date Approved
Fee Amount Permit Date
Date Fee Paid City or County Email Address
City or County phone number
Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement
CLERKS NOTICE: Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to event.
ONE SUBMISSION PER EMAIL, APPLICATION ONLY.
PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY PERMIT APPROVALS WILL BE SENT
BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGE.TEMPORARYAPPLICATION@STATE.MN.US
Minnesota
DULUTH
$25.00
hurbaniak@duluthmn.gov
218-730-5404
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CITY OF DULUTH LICENSE APPLICATION CITY CLERKS OFFICE (City of Duluth)

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Completed 3 August 2020

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