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,---- Minnesota Department of Public Safety a° <br /> I / I / f �� LIQUOR CONTROL DIVISION 4 • <br /> \ <br /> er a 444 Ccdar St., Suite 100 L, St. Paul, MN 55101 -2156 <br /> ' <br /> Fax (612)297 - 5259'x' <br /> (612)296 -6430 TTY (612)282 -6555 F <br /> * *TEMPORARY ** (Ju 2$ 29 sS 3 L I Q)at f e L S Lacs Celebrati <br /> CERTIFICATION OF AIR QIJi icktx tRMBCS C v U E <br /> No license will be approved or released until the 520 Retailer ID Card fee it retched by MN Liquor Control <br /> Workers Compensation Insurance Company Policy# <br /> LICENSEE'S SALES & USE TAX 1113 !1, To apply for sales lax number, call 296-6181 or 1- 800 -657 -3777 <br /> ISSUING AUTHORITY <br /> CITY OF COUNTY OF <br /> '' j.�cca Nitric ( Cor Partnership, Individual) DOB Trade Name or DBA <br /> Ceirt-�? nil lie 4rnra5 li'N <br /> Business Address City Zip Code <br /> &A te/n/, 31e M N 550 <br /> License Type (Check one or both) License Period County <br /> QQ On Sale sl Sunday From t IA, $ To ...LcLy 3C) A • e <br /> Ou Sale License Number On Sale Fee Sunday License Number Sunday Foe 1 Business Phone <br /> If a partnership, state the name and address of each partner, If a corporation, state the name and address of each officer. <br /> Partner /Officer Name / (First, middle and last) D013 Title Address <br /> . TZ Pre Cli.. <br /> `artner /Officer Name (First, middle and last) 13013 Title Address <br /> r lj.v.. µt>( V• T re , <br /> Partner /Officer Name a T middle and last) DOB Title Address <br /> � O,/cr l f `en <br /> The Licensee must have one of the following: / <br /> (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br /> Q,eck one <br /> =!A. Liquor Liability Insurance (Dram Shop) - 550,000 per person; 5100.000 more than ooc person; S10,000 Property Destruction; <br /> 550,000 and 5100,000 for Toss of means of support. <br /> a <br /> 013. A bond of a surety company with minimum coverage as specified above in A. <br /> cc <br /> OC. A certificate from the State Treasurer that the licensee bas deposited with the State, Trust Funds having a market value of <br /> 5100,000 in cash or securities. <br /> 0 Yes pi No During the past license year has a summons been issued under the Liquor Civil Liability Law (Dram Shop)? <br /> If yes, attach a copy of the summons. <br /> Check those items that aoply Circle one <br /> Transaction Type 0 New 0 Revoke/Cancel Suspend/Revoke/Cancelled <br /> 0 Transfer 0 Suspension From To <br /> Transfer of ownership from (Name and Address) <br /> 1 certify that this license was approved in an official meeting by the governing body of the city or county. <br /> •:ity Clerk's Signature Date <br /> IMPORTANT NOTICE <br /> All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of <br /> Alcohol, Tobacco and Firearms. For information call (612)290 -3496 PS 9011 -94 <br />