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Minnesota Department of Public Safety <br />1P <br />Alcohol and Gambling Enforcement Divistion (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certiffication of an On Sale lig,uor License, .2% Liguor license, -or Sundav Liquor License <br />Cities and Counties: You are NqUired by law to complete and sign this Forni to certify the issuance of the f llowing liqU01' <br />license. types: 'I.) City issuedcan sale intoxicating and Sunday liquor licenses <br />2) City and County 'Issued 3.2% on and off sale malt liquor beelises <br />Jle, LIcense Period From: To <br />Name of City or County Issuing Liquor License 6,i'�, <br />Circle One: c L iccn§ <br />License Transfel• Suspension Revocation Cancel <br />(fonner licensee name) <br />'S_ 2% 3. On sale <br />3.2% Off Sale <br />License typ e: (circle all that a ply) Qij.:.5�ae n t oxicqi ir, P r l I <br />ee: S. 3,2% Off Sale fee: S <br />Fee(s): On Sale License fee-.S Sunday License fee 3.2% On Sale f <br />Licensee Name: g- � � I //e /' / e_ DOB Social Security # <br />. (corporation, patinership, LLC, or Individual) <br />4- '11: <br />BUSi ness Trade Name E144,1^ 0 B us iness Address irp /Z J � I­ city <br />Zip Code 4'57/ 3 County q Business Phone Home Phone <br />I <br />Honic Address City Licensee's MN Tax ID # <br />(To Apply call 651 -296 -6181) <br />Licensee's Federal Tax ID # <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a corpol."ation, partnership, or LLC, complete the following for each partner/officer: <br />PartiicrJOfficer Name (First Middle Last) <br />DOB <br />Social Security # <br />Home Addi-ess <br />Wa rtne r/Officer Name (First Middle Last) <br />DOB <br />Social Security 4 <br />Home Address <br />Partner/Officer Name (Fir-st Middle Last) <br />DOB <br />SOCial SCCUrity 4 <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The hISUrance certificate <br />must contain all of the following: <br />1) Show the exact licensee name (corporation, partnership, LL C, etc) and business address as shown on the license. <br />2) Cover completely the license period set by the local city or coulity licensing authority as shown on the license. <br />Circle One: (Yes No) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Workel-s Compensation Insurance is also required by all licensees- Please complete the following-. <br />Workers Compensation Insurance Company NaMe: Policy # - <br />I Certify that this license(s) has been approved in an official meeting by the governing body of the city or corm y. <br />City Clerk or County Auditor. Signature Date <br />(title) <br />On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the <br />A <br />application for the Buyers Card, P lease call 651-215-6209, or visit our website at i,%? � jyjj <br />