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Attachment A <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGFD) <br />444 Cedar Street, Suite 222, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-655-"! <br />W17 M1111101,11, SUP" <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 3.21 1 f off sale malt liquor licenses <br />1/1/2011 <br />Name of City or County Issuing Liquor License C i ty of R,, seville License Period From: To. 12/31/2011 <br />Circle One: New License License Transfer Outback/Midwest II Suspension Revocation Cancel <br />(former licensee name) <br />(Give dates) <br />'r 11 Sun y Liqur 3.2% On sale 3.2% Off S ale <br />License type: (circle all that apply) a a o <br />On S <br />le Intoxicating_d <br />Fee(s): On Sale License feel Sunday License fee: $ 3.2% On Sale fee: 3.2% Off Sale fee: <br />Licensee O <br />Nme, utback Steakho <br />a use of Florida, LLC B 2910W <br />DO <br />(corporation, partnership, LLC, or Individual) <br />Business Trade Name Outback Steakhouse Busm'essAddress2181 Snelling Avenue NCity oseville <br />zip code55113 amsey <br />CoUnty Ramsey BusinessPhfit' (6-91) 697-122n, <br />HorneAddresS2202 N. West Shore Blvd. city Ta��a,, FL 33GO7j <br />(To apply call IRS 800-829-4933) <br />low on OM 11, -0 9 <br />Licensee's MN Tax ID • <br />(To Apply call 651-296-618 1) <br />If above named licensee is a corporation, partnership, or LL C, complete the following for each partner/officer: <br />Dirk A. Montgomery, CFO <br />Partner/ Officer Name (First Middle Last) DOB Social Security # M, A AA'- <br />Joseph J. Kadow, Exec, Vice President <br />(Partner/Officcr Name (First Middle Last) DOB Social Security # Home Address <br />Partner/Officer Namr, (First Middle Last) DOB Social Security # Home Address <br />rntoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />onust 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 licensmig authority as shown on the license. <br />Circle One: (Yes (9 During the past year has a summons been issued to the licensee under the Civil Liquot Liability Lawfo <br />Workers Conapensation Insurance is also required by all licensees: Please complete the following: <br />The Charter Oak Fire Insurance Co. I <br />Workers Compensation Insurance Company Name: Policy # TC2 QUB3 95J4 9 9 5 0 IV <br />r Certify that this license(s) has been approved in an official meeting by the goveming body of the city or county. <br />C.ity Clerk or County Auditor Signature Date <br />10 l'TUM-111 - <br />LJ!J"-1 <br />................ <br />(Fonn 9011-12/09) <br />