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Minliesota Department of Public Safety <br />4P <br />Alcohol and Gambling Enforcement Division (AGED) <br />4,44 <br />P <br />Cedar Street, Suite 133 St., laul, NIN 55101,-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />C -tification of an On, Sale Lig .2% ► Liguor 1i I cense, or Sunday Liquor License <br />et I uor License, 3 <br />Cities and Countl"es'-. You are required by law to complete and sign this forte to certify the issuance of the followfilg HqUOT <br />license types: 1) City, issued on sale intoxicating acid Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />N'arne of City loir County Issuing Liquor License License Period From: To: <br />Circle One: New License License Transfer <br />Suspension Revocation Cancel <br />(fon-ner licensee name), (Give dates) <br />License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale 3,2% Off Sale <br />Fee(s): On Sale, LiCeDse fee. 1 Sunday License fee-, $ 12% On Sale fee: $ 3.2% Off Sale fee: $ <br />Licensee, Name:- DOD Social Security# <br />(corporation, pahnersfiip', LLC', or hidividval) <br />Business Trade Nam, xy&)Fj /3.4j-z Am2_G z t Business Address 7,90- 1, ,kfe �t: C ity 6Z . zvt <br />If above named licensee is 1k a corporation, partnership, or LLC. complete the following for each partner/officer: <br />S< - ----- HA VAOW • <br />Part ner/Officier'Name (First Middle Last) DOB Social Security # &v.,r * jk it &, d"I UU I cbs <br />(Partner/ Officer Name (First Middle- Last) DOB Social Security N <br />Home Address <br />Partner/ Officer Name (First Middle Last) DOB Social SeC-Unit7y # Home Address <br />Intoxicating liquor licensees, must attach a certificate of Liquor Liability hisurance to this form. The insurance certificate <br />must contain all of the following-., <br />I)i Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) <br />Cover completely, the license period set by the local city or county licensing authority as shown on the license. <br />Circle One.- ('Ye�'N (� Durui7g the past year has a summon s been 'Issued to, the licensee under the Civil Liquor Liability Law? <br />O) <br />Workers Compensation Insurance is also required by all licensees. Please complete the following: <br />Workers Compensation Insurance Company Name: <br />Em <br />I Certify that this Jicense(s> has been approved in an of ciaJ meeting by the goveming body of the city or county. <br />City Clerk or County Auditor Signature Date <br />On Sale Intoxicat"' liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the <br />application for the Auyers Card, please call 651-215-62091, or visit our website at <br />(Form 901,1-5/06) <br />