2003-07-09 CC Packet - Laserfiche WebLink

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Name of City or County IsSuin!ucense License type: (check all that apply) On Sale Intoxicating sale License fee $ o New License ~.. l zl~ \ \ 0 S Minn~ota Deryartment ~f Public Safety. . 0 ALCOHOL AND GAM}jtING EN}'(JRCEMENT DIVISION (AGED) - --- .&J---"11 t.1L-~ 444 Cedar Street. Suite 133, SL Paul, MN 5101-5133 '~...::>S Telephone 651-296-6979 Fax 651-297-5259 TTY 651-282-6555 CERTIFICATION OF LIQUOR LICENSE OR APPLICATION FOR OPTIONAL 2 A.M. CLOSING LICENSE Licensees: Effective July 1, 2003, complete this form to apply for optional 2 A.M. closing license and make check payable to AGED for he amount indicated below under 2 A.M. Section. Note: New Intoxicating Liquor Licensees must also purchase a $20 buyers card before establishments will be approved by AGED to receive liquor shipments from wholesalers. Make check payable to: AGED Cities and/or Counties: You are required to submit this signed form to certify the issuance of all city issued on-sale intoxicating liquor and! or Sunday liquor licenses, and 3.2% malt liquor licenses. City/County must also si this form for 2 A.M. closing license applicants. 61\ ill '; . 3.2% I eveaige ~ Snndily Liquor III 2 AM. Option 3.2% License Fee $ (Sunday License Fee $ . l o SuspensionlRevOcation/Cancel rmer Licensee Name) (Give Dates) . . . DaB 5/'0//51 Social Security# '177- 70 - &/IW , ') Wt%+~- ~s R.,:6~~,:aUSiness Address _.JJ g I A Ild~ Home Address .. (form 9011-2AM) ", (7/03) l'1D,i" 'S'/, City C~-4.-v;"" .' 7Jf#') ftl.Co~ st. Ce,.vt.&".11t /1/1/1/ Licensee's MN Tax ID J; Lf :> 44 .~ (To apply for number calI 651-296-6181) If licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: Home Phone (R 5 J -7fd.~- 85''7"1 PartnedOflicer Name (First MIddle Last) DOB Social Security , Address PartnerlOfficer Name (First Middle Last) DOB SociaJ Security , Address DOB Social Security' . Address PartnedOflicer Name (First Middle Last) Intoxicating Liquor Licensees must attach a certificate of Liquor Liability Insurance to this fonn. o . 0 . . (Does not apply if only applying for Optiona12 AM license) The Insurance Certificate. must contain all of the following: 1. Show the exact Licensee name (corporation, partnership, LLC etc.) and business address as shown'on the license. 2. Cover completely the license period set by the city/county as shown on the license. DYes 0 No During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law. Workers Compensation Insurance is also required by aD licensees: Please complete the following: Workers Compensation Insurance Co. Name ~tI.lIJ t, ~ K Policy # 4J G J.J. 0 4 / '> 7(p /I ( . T,icensee'~ apphring for Ont1onal2oAM ~losbig license.. complete the fonowiil~ steps; . ' .' 1. Fill out the above application completely and check 2 AM box 0 above for license type. 2. Report your previous 12 months total in.toxicating liquor reCeipts by checking one of the following: Ia Up to $100,000 in gross annual receipts for intoxicating liquor - $200 2 AM license fee o Over $100.000 but not over $500,000 in gross annual receipts for intoxicating liquor - $500 2 AM license fee o Over $500,000 in gross annual receipts for intoxicatirig liquor li~ense - $600 2 AM license fee o 3.2 % Malt Liquor liCensees or Set Up License Holders - .$200 2 AM license fee o Did not sell intoxicating liquor for a full 12 months prior to this application - $200 2 AM license fee 3. Does your liquor license issuing city/county/township allow the sale of alcoholic beverages until 2 AM? 0 D Yes D No 4. Make check payable to: Alcohol and Gambling Enforcement Division (AGED) for the amount indicated above that you have cheeked. Mail check and this completed and signed certification/application fonn to the address above. I certify that this license(s) bas been approved in an official meeting by the governing body of the city/county and/or the city/county approves the sale of alcoholic beverages until 2 AM. .' City ClerklcountyA9:' 00 ;;Sir~. --rJ . . Date .... 0 ~o L;Ce~~SignatrJre .. ~. .tx-+-::- . Date . Gk7/r? (1 certify that to the best of my knowledge 1 have answered the above questions truthfully and correctly.)