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<br />~. <br /> <br />Min_""'" DeparImeIIt ofPublie Safety <br />Alcohol lIIld GlmbIlDg W6.~(""-l DIYbIoa (AGED) <br />444 Cedar S1Jeet, Suite 133, 81 Paul, MN 55101-5133 <br />Te1epholIc 651-201-7507 Fax 651-297-5259 T1Y 651-282-6555 <br /> <br />C..ntHirllflnll ~ _ OIl Sale 1 .Innn..l.........._ 3.2.~ U01IOr IIH.u. or fUmdsv I.imlftr 1.L-.n.... <br />CitiellIIld CountIes: You are required by law 10 comp1elc lIlId sisnlhis form 10 cenily tbc issuance oflbC foIlowiDg liquor <br />Iicensc types: 1) City issued on _ iDIoxicating IIIId Sunday Iiqoor liceDJlll <br />2) City IIIldCounty issued 3.2".4 0Jl1IIId off saIc malt liquor IiceDscs <br />Name of City or County Issuing Liqnor Lic:euse License Period FIOIII: To: <br />Circle ~..riiew L~ LiceDse Transfer Suspeosioo RevOCBlioll Cancel <br />'""""--~- . (fOrmor fice..- _) (Give....) <br />Liceosetype:(circ1eaDdJatapply) C;;:~~~~g--> (s~-J,.iciiW9 ~~ ~~>>. ~ <br />Fee(s): On Sale Liceosefee:$ Sunday Lice1lse fee: S 3.2%0& Sale fee: 5 3.2% Off Sale fee: 5 <br />LiceDsee NlII11e:,,-).... &./ fl U) DOB Social Security # <br />(colJl<""lioll, porIImohip. LLC. or 1ndiv;duoJ) ~ ':ftJf,.. <br />Business Trade NameJ4ilUl$ I<OA.AIH' .tb c.t~~~. Addrcss.:JOlf8 (I,;,,.l5I111dk... i6btyj\;"l'Kuu;-loC. <br />ZipCodc ~C)JLt,_A.NoM BusiDcssPhone ~1-l4i3-77'i1 HomePhone u:"l-'1~t1.JT~O <br />HOme Address5J S"f I~~ SI-. ~ . City I4u 'i 1"\ Licensee's MN Tax ID # 7-l-Y /~~/ <br />(To App1y..u 6S1-:z96,;;ISI) <br />Licensee's Federal Tax lD #...!:J5'-OS'&{.~3'" <br />(TolIIPIY..UIR8 100-12945133) <br /> <br />If above IUIII1ed ~)= is a COI)JOl'IItion, partnenhip, or LLC, complete !be followiPg for each p8ltlIer/officer: r J . J ~ <br />--:]AOM6..<;: . .~)AtJ'5e~ to~""'L .... st~ 1S7"f;!'\st,N d Ail I'll <br />PaJ1uorfOflloar NlIIIIC (Fuat MIddle Lul) DOB Social Scevrity # Home Addreoo <br /> <br />(PartnorlOfticcr N_ (F1I1l Middle Lul) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Home Address <br /> <br />POrtacrIOfliccr N8IIIO (Pint Middle Lul) <br /> <br />DOB <br /> <br />Social Security # <br /> <br />Home Address <br /> <br />Intoxicating liquor licensees must attach a cenif'1C8Ie of Liquor Liability Insunmce 10 Ibis fonn. The insunmce certitieate <br />must contaiD aU of tile foUowing: <br />1) Show the exact licensee IUIlIle (corporatioo, parl1lcnhip, LLC, eII:) IIIld business address as shown on tbe Iiceuse. <br />1) Cover ctlDIpIc1I:ly the license period set by tbe local city or COUD1y ~alll1t11mity as Ihown 011.1he 1iceDsc. <br />Circle One: (Yes No) During the past year bas a IQIDDIODS been issued to the IiCCllsce lIIlder the Civil Liquor Liability Law? <br />Workas Compensation Iasuranc:e is abo requiIecI by an licensees: Please CODlplcle die followilJs: <br />Workci'a ColPpensation IDsuraacc Company Name: B A\.1 Policy # 0 XI- t./;l7 20 ,_ <br /> <br />I Certify that this Hceue(s) has been approved ill aD official mcetina by !be governing body of the city or CClI1111y. <br />City C!elt or County Auditor SigDature Dale <br />Clitia) <br /> <br />00 S_..toskatinl Uquor U__ mut 1110 DlII'Cbae a 520 Retailer B!I)'en Card. To...... die <br />applladOD for die BUJen Cant, .._ all 65f-21U209, or Wit ourwellilte at WWW.dDs.sblb>mn.us. <br /> <br />(Form 11011-5106) <br /> <br />-47- <br />