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s � <br />AI cahol R Gampliiry Enfwcemw�l <br />Minnesata Dcpa.rtment of Public Safety <br />AIcohol nnd Gambli�qg Enforcement Diviaian (AGED} <br />444 �edar Street, Suite 222, S�. Paul, MN SS1Q1-S133 <br />Tclephone 651-201-75�7 Fax 651-297-5259 TTY 651-282-6555 <br />Certiflcation aia� Un ��le Liq�o�License 3 2% Lfquor If�,ense or Sue�av LiauQr L,i�rg, se <br />Ci,�es and Caunties: You aze requured by law ta complete aud sign tbis forn:z to �ertify the issuauce af tha fvllowutg liquor <br />licer�se types: 1) City issued on sa.le intoxicating aud Sunday �iquor Iicenses <br />2� City and Couuty issued 3.2°!0 on and off sal� mait liquor licenses <br />Narne af City ar Issuing Liquor License �o� ���.`\� L'zcense Period From: To: <br />Circle 4ne New Liaez�se icense Transfer Suspensia� Revocation Cancel <br />(former Iicensee name) (Give datss) <br />License type: (circle all that applyj On Sale Inta�c�ic.ating Sunday Liquar 3.2% On sade 3.2% Off Sale <br />Fee(s}: Qtz Sal� Lic�nse fee:$ Sunday License fee: $ .°Is On 5a1e f�e: 3.2% �i�Sale fee: $ <br />Licensee Name: � e� �Gc1's _�c�� Qf QE ,,�<, �-hC. DOB Soeial Security # <br />(corPoratian, Pariners p .C, or individual) <br />1�� -a�� 5,.����.�, p�a�.cv <br />Business Trade Name V`� ���1 a B�siness Address �} ���, `� City �0`y�J . t`Qj <br />Zip Code \\�CountyCL. �e Busiuess Phone �u.�1 �1� ��1\�3 Home Phone ��� �`'��0 03'�.�1 <br />Hnme Address��o �'1� � 01.�,��� �,�,-h CiLy �c''.\\�.Y�..aRf' `C�`�c�, Licensee's MN TaYC ID#�J3�"�\\�,._ .. <br />(Ta Apply call 651-296-6i Bl) <br />Licensee's Federal Taai ID # _ �� "''4 �'�.���� ���� <br />(I'o apgly call IRS B{10-8Z9�933) <br />Lf abovc named licansee is a cctrporatia�, partnership, or LLC, camplebe the failawing far each partner/nf�cer� <br />, <br />5�0, t�'1��r. %�1cl�t'_2 �'� � t?.R.�t` <br />� <br />PartneriOfficer I�Iame {First Middle Last} �� Spcial Securitv # �` Honae Addreas <br />� � � � � �Q�����],, ,�Ov,.�'S ,„, � � <br />{PsrmerlOfficer Name (Fiist Middle S�ast) <br />PartnertOfficer Name (i�irst Midd]e Last) <br />�aB <br />�s: <br />s���� se�ur;�y # <br />S ociai Security # <br />Home Address <br />Home Addreas <br />Intoxicating liquor licensees must attach a certificate of Liquar Liability Iusurance to this farn�. The insurance certificate <br />must contain all of the foliowing: <br />1) Show the exaet licensee name {corparation, partnership, LLC, etc) and business address as shown on the iicense. <br />2) Cover completel th� Iicense per�c�d set by the loeal eity or county iicensi�g authority as shown on the license. <br />Cirele Ona: (Yes� i3uring the past year has a su�un.ons been i�sued to tha licensee untier the Civil Liquar L'rability Law? <br />Workers Compensation u►surance is also requ�red by a.11 licensees: Piease complete the fallawing: <br />Warkers Compensation 7nsuran;ce Company N�rne: � C t�d 1.��t � Policy #��' �'�'� �\��j� <br />I Certify that this license(s) has been approved in an afficial naeeting by the governing body of the city or caunty. <br />Gity Cler�, ar County Auditor Signatute Date <br />(titie} <br />Uu Sale Into�icating tiquar licens�es must �iso purchase a$24 ReYailer Buyers Card. Ta obt�ain the <br />spplication for the Buyers Card, please call 65i-ZQ2�7504, ar visit our website a# www.d s.state.mn.us. <br />{Forn;t 9D11-17J09) <br />