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OR <br />j <br />(i n i i r (s n <br />Minnesota Departmeiit of Public safety <br />Alcohol and Gambling Enfoi-cement Division (AGED) <br />444 Cedar Street, Suite 1-33,, St. Paull M-N 55101-5133 <br />Telephone 6,51-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of an On Sale Liguor License '3.2%1 Liquor license or Sunday Liatior License <br />Cities and Counfies: You � -irc requ ired law to complete and sign this form to certify the issuance off` t1 follow Hig liquor <br />license types: 1) City issued on sale intoxicating and Sunda liquor licenses <br />2) City and County issued 3. °. Ion and off sale malt liquor licellses <br />- / - To: <br />'Neame of City or Ciounty Issuing Liquor License(.1L oi��-12L'5ev, //d, Licensiz� Period From.: <br />Circle One: Liciense Transfer Suspension Revocation Cancel <br />(former liciensee name) <br />("Give dates) <br />License type- (circle all that appiy) 0 ic -itoxicatn1g), (�7 3.2% On sale 3.2% Off Sale <br />ij_ I h <br />Fees n S a I e License -fee S f Sund ay License en s e fie e 3.2 On Sale le fe e: S ,2% Off Sale <br />L <br />&V 144 <br />L i cen see N �am e Y, 9 /D 00,q 0 *41, i Ile_ Z _c D OB <br />(corporation, partnership, LLCM, or liidiv ideal ) <br />Business Trade Nam Business Address 1-o �el_ City <br />e <br />Iq <br />Zip Code ;3-//13 County Business Phone.-I-1.­ Horne Phone <br />Home Address city Licensee's MN Tax ID <br />(To Apply tali 51-2 96-6 18 1) <br />Licensee's Federal Tax ID <br />(Tic apply call IRS 800-929-4933) <br />If above named IiCerl-See is a corporation, partnership, or LLC, complete the following or each partner/offjQer: <br />(Partner/Officer'-Name (First Middle Last) <br />Pailner/Officer Name (First Middle Last) <br />DOB Social Security # <br />DOB Social Security # <br />DOB Social Security # <br />Home Address <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form.. Tile insurallice 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 oji the license. <br />2) <br />over completely the license period set by the local city or county licensing authority as shown on the license. <br />Circle One: (Yes Na ) During the past year has a summons been issueld to the licensee under the Civil Liquor Liability Law? <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br />P olicy <br />Workers Conipensation Insurance Company Name(4 I 11, ce-1 / I - �5, , I <br />I Certify that this license (s) has been approved in an official meeting by the goveming body of the city or cloullty, <br />City Clerk or County Auditor Signature (title) Date <br />011 Sale Intoxicathig liquor licensees must also Purchase a $20 Retailer Buyers Cap d.1 'To obtain the <br />application for the Buyers Card, please call 651-215-62,09, or visit our website at wWw'id <br />(Fomi 9011-5/06) <br />