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52 <br />Attachment A <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (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 />Certification of an On Sale Liquor License., 3.2%, Licitior license, or Sunday Liquor License <br />,Citiles and Counties.* You are required by law to complete and sign this form to certify the issuance of the following liquor <br />license 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 of City or County Issuing Liquor License.... License Period From: To- <br />Circle One: License Transfer (fornier licensee name) Suspension Revocation Cancel <br />License type: (circle all that apply) unday Liquor 3.2% On sale 3,2% Off Sale <br />Fee(s): On Sale License feeS Sunday License fee: S 3.2% On Sale fee: S 3.2% Off Sale fee: S, <br />Licensee Name: D8 <br />Coin Lit Social Security # <br />"�Uy)fW Ole. O <br />Leo oration, partnership,, LAC, or Individual) <br />If abovie named, licensee is a corporation., partnership, or LL C, complete the following for each partner/officer: <br />e- ic L <br />Partner /Officer Name (First Middle Last), DOB Social Security -4 <br />ot, <br />(Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />Partner/ Officer Name (First Middle Last) DOB Slocial. Security # Hame Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this forni. The insurance 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 oil the license. <br />2) Cover conipletely, the license period. set by the local city or count y licensing authority as shown oil the license. <br />Circle One: (Yes(yjol During the past year has a summons been issued to the licensee under the Civil Liquor Liability L'-aw 9 <br />Workas Compen,sati,on, Insurance is also required by all licensees.. Please complete the following: <br />I -I P, <br />Workers. Coinipen,siati,on Insurance Complany Name- U I I 3n Policy # <br />in, i'( " - --C-A P 0 175 4 0, <br />I Certify that this license(s) has been approved in an official ineeting by the governing body of the city or county. <br />City Clerk or County, Auditor Signature Date <br />(title) <br />On Sale intioxicating, liquior licensees must also purchase a S20 Retailer Buyers Card. To obtain the <br />91. 1 �!.. <br />application for the Buyers Card, please call 651-215-6209,orvisit our website at <br />(Form 9011-5/06) <br />