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<br />.~ <br />t=:3 <br /> <br />Minnesota Department of Public Safety <br />ALCOHOL AND GAl\1BLING ENFORCEMENT DIVISION (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN5101-5133 <br />Telephone 651-296-6979 Fax 651-297-5259 TTY 651-282-6555 <br /> <br />(form 901l-2AM) ... <br />(7/03) <br /> <br />CERTIFICATION OF LIQUOR LICENSE OR APPLICATION FOR OPTIONAL 2 A.M. CLOSING LICENSE <br /> <br />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 <br />amount indicated below under 2 A.M. Section. Note: New Intoxicating Liquor Licensees must also purchase a $20 buyers card before <br />establishments will be approved by AGED to receive liquor shipments from wholesalers. Make check payable to: AGED <br />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 <br />Sunday liql:or licenses, and 3.2% malt liquor licenses. City:<:ounty ~~,t Jlso Si~ form for 2 A.M. closing license applicants. <br /> <br />Name of City or County Issuing License_ ~~/'/?U ... ~ <br /> <br />License type: (check all that apply) f;2( On Sale Intoxicating 0 3.2~ Malt Beverage ~. Sunday Liquor V2 A.M. Option <br />(Un sale License fee $ ) (3.2% License Fee $ ) (Sunday License F~ : ) <br /> <br />o New License 0 License Transfer 0 Suspension/Revocation/Cancel <br />. (Former Licensee Name) <br />Licensee Name: ()r}OLlIV11"J I/'J_ &~~ ~ ~&lJJt 7~ 1..1"- Social Security# <br />(corporaWtl/rshiP, C, or Individual) . ~-1- <br />T"de ~"."" .{ 12 /0 l n"~nCO' Addceo, 7 Og ~~AAfI.(j ~",.:b <br /> <br />Zip Code ,,-l;_ 0 3. f( County /1lDv P{h Home Address . . <br /> <br />Business Phone &5/' l.f J f.:; - ,9S f:, Home Phone l_ \-/ .,) b I ' ,~ ) yi Licensee's MN Tax ill 3 b b ~.., J-/'J <br />r' . (To apply for number call 651-296-6181) <br />If l~. n.. see is ~o~partnership, or LLC, complete the t. ollowing for ~ <br /> <br />f/.. t/ /)/11/10 ;J101U fA' --~-:.1-_ <br />Partner/Officer Name (FlISt Middle Last) DOB Social Security # . (;5 ID A~ess d." A' ~ ~ <br /> <br />~~O-.3.- ? <br /> <br />(Give Dates) <br /> <br />Partner/Officer Name (FIrst Middle Last) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Address <br /> <br />Partner/Officer Name (First Middle Last) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Address <br /> <br />Intoxicating Liquor Licensees must attach a certificate of Liquor Liability Insurance to this form. <br /> <br />(Does not apply if only applying for Optional 2 AM license) The Insurance Certificate must contain all of the following: <br />1. Show the exact Licensee name (corporation, partnership, LLC etc.) and business address as shown on the license. <br />2. Cover completely the license period set by the city/county as shown on the license. <br />DYes 0 No During the past year has a summons been iss~ed to the licensee under the Civil Liquor Liability Law. <br /> <br />Workers Compensation Insurance is also required by an licensees: Please complete the fonowing: <br /> <br />Workers Compensation Insurance Co. Name Policy # <br /> <br />T .kensee's a n!"inO' for Ontiorra! 2 AM dosino !ie~nse ccm""ktc the foUuwhr ste- s; <br /> <br />1. Fill out the above application completely and check 2 AM box above ,for license type. <br />2. Report your previous 12 months total intoxicating liquor receipts by checking one of the following: <br /> <br />o Up to $100,000 in gross annual receipts for intoxicating liquor '- $200 2 AM license fee <br /> <br />"5rOver $100,000 but not over $500;000 in gross annual receipts for intoxicating liquor - $500 2 AM license fee <br /> <br />6 . Over $500,000 in gross annual receipts for intoxicating liquor license - $600 2 AM license fee <br /> <br />o 3.2 % Malt Liquor licensees or Set Up License Holders - $200 2 AM license fee <br /> <br />o Did not sell intoxicating liquor for a full 12 months prior to this application - $200 2 AM license fee <br />3. Does your liquor license issuing city/countyltownship allow the sale of alcoholic beverages until 2 AM? 0 Yes 0 No <br />4. Make check payable to: Alcohol and Gambling Enforcement Division (AGED) for the amount indicated above that you have <br />checked. Mail check and this completed and signed certification/application form to the address above. <br /> <br />I certify that this licensees) has been approved in an official meeting by the governing body of the cityJcounty and/or the city/county approves <br />the sale of alcoholic beverages until 2 AM. <br />City Clerk/County Audito~ture -, Date <br />~ () rn -r-- 6" ;/ - u() -, <br />Licensee Signature ~<~ / '/ t?'/-~U- Date - ~ _.." <br />(J certify that to the best of my knowledge J have answered the above questions truthfully and correctly.) '-' . <br />