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<br /> <br />(f) <br /> <br />Alcah1ll6 Gambling Enforcemlnt <br /> <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 <br />Telephone 651-296-6979 Fax 651-297-5259 TIY 651-282-6555 <br /> <br />Certification of an On Sale Liouor License. 3.2% Liouor license. or Sunday Liouor License <br /> <br />Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor <br />license types: 1) City issued on sale intoxicating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses . <br /> <br />Name of City or County Issuing Liquor License C 6"f~e. III t.L l. License Period From: ~ 1",<1 To: ~..ep~ <br /> <br />Circle One: ~w License 1 License Transfer Suspension Revocation Cancel <br />~ ~ (former licensee name) (Give dates) <br /> <br />License type: (circle a1ltbat apply) ~ Sale Intoxica~ ~ Li~ 3.2% On sale 3.2% Off Sale <br /> <br />Fee(s): On Sale License fee:$ ~SOO.oO Sunday License fee: $ ~(JO~DO 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br /> <br />Licensee Name: .s4UAtA( !JII1JMV(JD1'4' J -$',vl. DOB lJ - .30-1 Y Social Secmity #_ <br />(corporation, parlnership, LLC, or Individual) <br /> <br />Business Trade Name ~~! L'iAA-IJ- blhLL Business Address 7Q9i ~;tJ{iP."'LU dn, City Ct.Jt'lRIIII,"c.. <br /> <br />Zip Code jSQ3g County tljtJ~ Business Phone '51 - 053 ~ 779L- Home Phone 651-'107- 7 ~dJ <br /> <br />Home Address ..'i'l'l-S JS7 '1! S1: M City till bo, Licensee's MN Tax ID # gJ- OSOS~ <br />(To Apply can 651-296-6181) <br />Licensee's Federal Tax ID ## JO- i.JJ~7g~3 8 <br />(To apply can IRS 800-829-4933) <br /> <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />/tJtfA4L- JAtt1l.5 SAb6R IJ-3o-h~ .5&J<jS lS19 S7.~ <br />Partner/Officer Name (First Middle Last) DOB Home Address <br /> <br />(partner/Officer Name (First Middle Last) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Home Address <br /> <br />Partner/Officer Name (First Middle Last) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Home Address <br /> <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />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 /> <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license. <br /> <br />Circle One: (Yes €;J During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br /> <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br /> <br />Workers Compensation Insurance Company Name: 8atuy AMMtJJ-S11lA1'uA.1 Policy# We ~'JtJY J~7Qly()J <br /> <br />I Certify that this Iicense(s) has been approved in an official meeting by the governing body of the city or county. <br />City Clerk or County Auditor Signature Date . <br />(tille) <br /> <br />On Sale Intoxicating Uquor Heensees must also purchase a 510 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please call 651-115-6109, or visit our website at WWW.dDs.state.mn.us. <br /> <br />(Form 90 II-II/OS) <br /> <br />4t <br />