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CITY OF GEM LAKE <br />Heritage. Hall <br />4200 Otter :Lake Road ! Gem Lake,.MN N 55110 <br />651-747-2790/92 651-747-2795 (fax) <br />- E-mail cityr?g(einlakeinn.org <br />Edible Cannabinoid Products License Application <br />Pursuant. to City Drdinance No.4i.4J,: as it relates to the setatl sale of edibto cadnabinoid products, no person may directly or <br />indirceIly or by means of any device .keep 1'or retail sale, sell at retail, offer to sell or othcrwiw dispose of any edible can nabinoid <br />products at any place in Gem [,akc ►vithout first having obtained a license fforn the City, Issued in.acc0rdancc wi1b the'City. Code. <br />Instr6ctions: Return completed application in:person, by mai],. or email, sent to the .contact information Iisted:at the top. ;of this <br />application, witli the required documental inn and applicable ices. <br />Required: <br />• Comp.leted Background Check Authorization Form.{page 2} <br />Attach a cop of your driver's license <br />• Attach proof of workers' cbmpedsation "insurance, pursuant to MN Statute, Section 176.182.. Utile ss.6ne of the <br />foiIn►ving. applies: <br />a I have no employees <br />a [ ani self -insured (include permit:io.sclf-insure) <br />1 have no employees who are covered by wo.rkers'.compensation law <br />Attach applicable application fee as provided in the .Fee .Schedule; including the application, background fee, and <br />Iice rise fee..Chcck madc:payable to the City of Gem Lake <br />■ Attach. a sealed site plan. <br />Business Information <br />Name of Business; <br />Business Address:. <br />Contact Person: <br />Business Phone: <br />MN Tax -ID No.: Federal Tar. ID No.; <br />0wuer[0 Information <br />Business 0►vner: <br />Residential Address; <br />City; <br />Daytime Phone: <br />.Business 0►vner: <br />[residential Address: <br />Email: <br />state: zip; <br />City: State: Gip: <br />Daytime Flom: <br />Email: <br />Business Eligibility [check all that apply}: The City shall only issue a license to sell cdilile.cannab'inoid.products to an eligible <br />business: that qualifies to recciv.0 a Because under the:rcquirements.of Ordinance No. 1..45, An.etigi6I.e business has an active <br />tobacco Iicense to set Hobacco or. tobacco producIs.at retail or has an active on -sale or oIT sale liquor license to. self intoxicating <br />liquor, Which active licenses) does the bt;siness.ltold? <br />El Tobacco License Off -Sale Liquor License On - <br />Sale Liquor License <br />City Ordinance Review (required) <br />1 have reviewed and understand.0rdinance No,.145 and will follow it in its entirety. I also understand that failure to comply <br />Wit the ordinance inav result in adininistrati■a pemllties, suspeasion or:revocation 0Cthe. Iicense. <br />S..ignature.ofBusiness Owner: Date: <br />