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MINIMA <br />Mimiesota Department of PLiblic. Safety <br />Alcohol and Gambling Enforcement Divislion (AGED) <br />1 <br />444, Cedar Street Suite 1 55' <br />33, St. Paul, MN 101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of On Sale Uuuor License, 3.2%liquior license, r Sund4y—UgUor License <br />Cities 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 Liccnse Roseville <br />Circ,le One -(Ne5j i n License Transfer <br />License Pler,iod From: 11/14/08 To: 12/31108 <br />(former licensee name) <br />Suspension Revocation Cancel - <br />(Give dates) <br />License type: (circle all that apply') On Sale Intoxi c ati.ri g Sunday Liquor. 3.2% On sale 3.2% Off Sale <br />Fee(s) - On Sale License fee: $ -7 cx=pposunday License fee: $-gpG, cXD 3.21% On Sale fee - —3.2% Off Sale fee, $ <br />Licensee Name. Mac &1quisition LL C DOB. N/A Social SecuritY W N/A <br />(corporafior4 partnership, LLC, or Individual) <br />Bus'mess Trade Name Romano's Macaroni Grill Business Address 1705 Highway 36, Ste 675 <br />Zip Code 515113 County_Ra�msey <br />Home Address see blielow <br />IMMEMMMM'dwo, <br />City see below <br />1,11censee"s F6deral Tax ID A 26-310963612 <br />(To apply call IRS 800-829-49333) <br />City Roseville <br />Home Phone <br />Licensee's MNT Tax ID # 9628905 <br />jo App I y call 65 1 - 296-618 1) <br />if above namied licensee, is a corporation, partnership, or LL C, complete the following for each partner/officer- <br />Joshua 01shansky, Pres�!denl, CE0, VP, Sec. <br />Partner/ Officer Name (First Middle Last) <br />octal Security <br />MOM=- M <br />(Partner/Officer Name (first Middle Last) DOB Solictal Security # Home Address <br />Pariner/Officer Name (First Middle Last) DOB social Security 4 <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all of'the following: <br />1) Show the exact licensee name. (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license. <br />1% <br />0"'h' <br />ffiMMMWr <br />Circle One-,(Yes[�oj)i During the past year has a sununons been issued to, the ficensee under the Civil Liquor Liability Law? <br />Workers, Compensation Insurance is also required by all licensees. Please complete the following: <br />Workers Compensation Insurance Company Name,- Policy -# <br />I Ce,rdfy that this ficense(s) has been approved in an official meeting by the gloveming body of the city or county <br />City Clerk or County Auditor Signature Date <br />(tide) <br />On Sale Intoxicating liquor licensees must also purchase a $20 Retailler Buyers Card. To obtain the <br />app�llication for the Buyers Card, please call 651-201-7504, or Visit our website at R;iy-w.dPs.state.mn.us. <br />(Fonn 9,011-5/06) <br />