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Minnesota Departmem of Public Safety <br />Alcohol and Gamblin.g Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St—Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-29,7-5259 T7Y 651-282-6555 <br />il <br />Certiricatlion of an On Sale U*Qji-or License., 3.21% <br />Jeense, or StindavL'itmor License <br />Cities and Counties. You are required by law to complete and sign this form to cert-IFy the iss.uancc of the follo�vfflcr liquor <br />hicelisle types-• 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 or City oir Colanty Issuing Liquor License 11 C License Period Froni: To- <br />C11-Cl.c One: License License Transfer Suspension R(!vocation Cancel <br />jomier lice-jiseu iname) {Give dw-es.)- <br />Licclise t,ylpe: (circle alf that apply ) �unday Liquor 3.2% On sale 3 2% Off Sate <br />FcQ(s): On Salle Licicnsefee:S Sunday License fee.- S <br />3,2% On Sale fee S 3,2% Off Sale fee; S <br />Licensce Name: Co i L-e- o DOB <br />-- -- S0631 SCCLIFIty -11 <br />` Cvorauom, partnership, Lk, or Individual) <br />business Trade Business Address 1 -(2 <br />Zip Code <br />I County Business Phone 1b-S--k'V',.,L44 - Zco�i 0 Ho me Phone <br />It" cabovie narried, licensee is a corporation, partnership, or LLC, complete the followi ng for each partner/officer: <br />11 <br />6e <br />PartrWOfficeir Name (First Middl-eLasi) D08 social secttrity, <br />(Parxtier/Officer Name (Fl.rst Middle Last) D08 Social Security Home Address <br />Pai�ljlcr/Officer Name (Fir'sit Diddle Last) DO-13 Social securtry 4 <br />Home Address <br />Intoxicating liquor licensees I <br />icensees must attach a certificate of Liquor Liability Insurance to this form, The insurance cernficate <br />must contain all of the following: <br />1) Show the (wict licensee name (corpornion, partnership, LL C, etc) and business address as shown on the license: <br />2) Cover cow:pletcly the license period. set by the local city or courity licensing authority as s1lowl, oil til-c licellse. <br />Circle One- (Yie <Q1.0'.) DUI-ing the past year has a summons been issued, to the lliccnsce under the Civil Liquor Liability .Lc \0 <br />Workicrs Compensation Insurance is also required by all licensees: Please compk-,te the following., <br />\Vot-keys Compensation Insurance Company Narn-e:,. 1~ 41 Policy #--CA e Q Z. 0 <br />I Certify that this 111censiel(s) has boen, approved in an official rneeting, by the governing body of the city or county. <br />City Clerk or County, Auditor Signature Date <br />e): <br />On Sale Intioxicattna fliquor fic-ensees must also purchase a, $20 Retailer Boyers Card,. To obtaill the <br />application for the fiuyer�s Card,, Please call 651-215-6209, or viisit our website at w-�N m,N Lip s.si:i [Lt.1T1",'1,H N. <br />(P'or'ni 90 11, 5/06) <br />