2003-07-09 CC Packet - Laserfiche WebLink

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~# 'l~ _6__ Minnesota Department of Public Safety ALCOHOL AND GAMBLiNG ENFORCEMENT DIVISION (AGED)- 444 Cedar Street, Suite 133, S1. Paul, MN 5101-5133 Telephone 651-296-6979 Fax 651-297-5259 ITY 651-282-6555 (form 9011-2AM) (7/03) .,' CERTIFICATION OF LIQUOR LICENSE OR APPLICATION FOR OPTIONAL 2 A.M. CLOSING LICENSE Licensees: Effective Iuly 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 re{;eive 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 liCJl'O'" li....... and 3.2% mal. liquor li==-~ sign ~ ~~2. .M. cloSing license applicants. Name of City or County Issuing License d J1/~p~ i)~ ,ft.' .,' License type: (check all that aPply) M On Sale Intoxicating ~ 3.2% Malt Beverage Sunday Liquor 'V2 A.M. Option . ~ sale License fee $ (3.2% License Fee $ ) (Sunday License F~ . ) o New License 0 License Transfer 0 SuspensionlRevocationlCancel . (FormerLice~e) Licensee Name: fl1OC1l1JlO.llU ~ ~ l/Yi" l.._ Social Securityll ./ (co~on, artn 'p, or Individual) . ~-T 1hdeN.",. _~ i/o );l -- llnshlcs;;Add=; 7Dj,J.~~(j ~..;;& Zip Code ~ () 3. t' County /1 /lJVu'A- Home Address Business Phone ~l' ljJIo - ;)9.i~ Home Phone t_ \/ ~.)'I':J )Yi Licensee's MN Tax ID 3 b ." ~ ?-Icj ~ ('lb apply for number call 651-296-6181) If ~see is. o~ partne~hip, or LLC, complete the following' for each p~er/officer: 1741./ lJlJVIO D /VTA "S ~- lJ ~ -'fr 7/tj'D Panner/ot1icer Name (First MIddle Last) COB Social Security # ~/D Address (Give Dates) Panner/Officer Name (First MIddle Last) COB Social Security # ~~ ~O.3~/ Address PannerlOflicer Name (First Middle Last) COB Social Security # Address Intoxicating Liquor Licensees must attach a certificate of Liquor LiabDity Insurance to this form. (Does not apply if only applying for Optional 2 AM license) The Insurance Certificate must contain aD 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. (J Yes (J 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 all licensees: Please complete the following: Workers Compensation Insurance Co. Name Policy # :r ..~en~'s app!ymg for Optional 2 AM closing liecnsc. complete the fullowing stt:ps: 1. Fill out the above application completely and check 2 AM box above for license type. 2. Report your previous 12 months total intoxicating liquor receipts by checking one of the following: o Up to $100,000 in gross annual receipts for intoxicating liquor - $200 2 AM Ii~ fee '[lover $100,000 but not over $500,000 in gross annual receipts for intoxicating liquor - $500 2 AM license fee 6' Over $500,000 in gross annual receipts for intoxicating liquor license - $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 Yes 0 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 licensees) has 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 Clerk/County Audit~ture TI Date Licensee Signature ~ ~ Date 6 -Ie. - OJ (1 certify that to the best o/my knowledge 1 have answered the above questions truthfully and correctly.) .