2003-07-09 CC Packet - Laserfiche WebLink

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Minnesota De_nt of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION (AGED)- 444 Cedar Street, Suite 133. St Paul. MN 5101-5133 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 sign this form for 2 A.M. closing license applicants. Name of City or County Issuing License C~N I~;, 1/,7/6 License type: (check all that apply) . On Sale Intoxicating .3.2% Malt Beverage . Sunday Liquor ~ 2 A.M. Option (On sale License fee $ ) (3.2% License Fee $ ) (Sunday License Fee $ ) o New License 0 License Transfer 0 SuspensionlRevocation/Cancel (Former Licensee Name) (Give Dates) Licensee Name: WI i/L;_ 13,; &M DOB4if/~ ~ Social Security# If ')1 .. J2.. t. Z D 9 (corporatiOIl, partnership, LtC, or Individual) r IJ TraG.::Namc Iii/I,! ~ J&;".~.,I"', f.ltfl.GBusil1es~AdUress ?~93- (f,,}f9;'~ City ~"".jyr,..,I/c Zip Code 5 oS/) 3 , County 4/1 tJ It! ~ Home Address I ~ ~ 8 ().. )i' ~ tJ,,/ Sf. Business Phone {'51..t~J.. ),'; I Home Phone 'J~.J" ~,1~- /p~~ Licensee's MN Tax ill /5/ t I ~ 0 (To apply for number call 651-296-618 I) If licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: ~/ir#;.. 13rsl~ 1hft'r '7j/..)2-~'!4P /f{S'a'~- y~tf!J'" sl erlOfficer Name (First Middle Last) DOD Social Secority # Address ~ . (form 9011-2AM)' " (7/03) Palmer/Officer Name (First Middle Last) OOD Social ~ty # Address PannerIOfIicer Name (First Middle Last) DOD ,ty# Address Intoxicating Liquor Licensees must attp.... ;9,uor Liability Insurance to this form. \ (Does not apply if only applying for Opv', ~. ~ Certificate must contain aU of the following: 1. Show the exact Licensee name \. 'D r ,\d business address as shown on the license. 2. Cover completely the license pen ~ ~ the license. D Yes ~ No During the past J .he licensee under the Civil Liquor Liability Law. Workers Compensation Insurance is a. ~ ..s: Please complete the following: Workers Compensation Insurance Co. Nan. ,*M,~ toil. flil$'I,A-f-lSrs Policy# We... lZ,-IJ'f..13()13~-()(J Lieer.see's np-p1ying for Optiunal 2 MI. d~liceTJse. complete the foHowing steps: 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 license fee QD 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 intoxicating liquor license - $600 2 AM license fee .0 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? ~ Yes D No 4. Make check payable~o: Alcohol and Gambling Enforcement Division (AGED) for the amount indicated above that you have checked. MalI check and this completed and signed certification/application fonn to the address above. I certify that this license(s) 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 unti12 AM. City Clerk/County A r gnature . Date Licensee Sign Date ~ Is 4/t:J.J best ofmy knowledge I have answered the above questions truthfully and correctly.) .