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Minnesota Department of Public Safety
<br />Alcohol and GanibUng Enforcement Division (AGED)
<br />444 Cedar Street, Suite 222, St. Paul, MN 55101-5133
<br />Telephone 651-201-750 Fax 651-2971-5251 9, TTY 651-282-6555
<br />Attachment A
<br />Certification of an On Sale LiglLor License, 3.2% Liguor licensee oir Sund#y Li or License
<br />W
<br />Citi,es, and Counties: You are required, by law to complete and sign this form to, certify the issuance of the following liquor
<br />license type�s: 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 />Name of'City or, County Issuing Liquor License Cli qty of Roseville License Period From- 1/1/2011
<br />To- 12/31/2011
<br />Circle One: New License L'i,cen,sle'Trans�ferOlu,tbia,ck/M:Ldwest II Suspension Revocation Cancel
<br />(former licensee name)
<br />License type: (circle all that apply) On Salle Intoxicating Sunday Liquor 3.2% On sale
<br />Fee(s): On Sale License fee:$, Sunday License fee: $ 3.,2% On Sale fee: $
<br />outback Steakhouse, of Florida, LLC
<br />Licensee Name:
<br />(corporation, partnership,1 LLC, or Individual)
<br />0
<br />(Give dates)
<br />Business Trade Name Outback Stleakhouse Business Aiddress2181 Snellinq Avenue N.CitV Roseville
<br />Zip (Code 55113 C 0 U n ty_ R� a mit i �ste yy
<br />Miusil" P • - 4
<br />hone (51) 69712,2
<br />inessil Home Phonz
<br />City Tia mi, py cat FF Lu .33 33 66 00 7,
<br />Licensee's Federal Tax II) #
<br />(To apply call IRS 8001-829-49331)
<br />Licensee's NIN Tax ID #
<br />(To Apply call 651-296-618 1)
<br />If' above named licensee is a corporation, partnership, or LLC, complete the followin,g for each partner/officer:
<br />Dirk A,., Montgomery, CFO
<br />Partner/Officer Name (First Middle Lag), DOB Social Security, 4 A
<br />Joseph J'. Kadow, Exec. Vice President
<br />................
<br />(Partner/Officer Name (First Middle Last)
<br />Pa,rtn,er/Oleer Namr (First Middle Last)
<br />DOB Social Securitly-y- #'
<br />Social SecurityLl�
<br />1079—awneld
<br />Home Address
<br />C ' U, "Pm�
<br />I' cle One (Yes Uo During the past, year has a, summons been issued to, the licensee under the Civil Liquor Liability Law?
<br />I I
<br />Workers Compensation Insurance is also required, by all licensees: Please complete the following:
<br />The Charter Oak Fire Insurance Co.
<br />TC20TJB39SJ499509
<br />Workers, Compensation Insurance Company Name,: Policy #
<br />I Certify, that this licenses) 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 />(title)
<br />On Sale Into eating lliquor Hicensees must also purchase a $20 Retailer Buyers Card., To, obtain the
<br />application for, the Buyers Card, please call 651-201-7504, or vislit our website at wwwAp
<br />(Folun 91011-12/019)
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