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Attachment A <br />Minnesata Department af Puhlic Safety <br />AlcohoI and Gambling Enfarcement Division (AGED} <br />444 Cedar Street, Suite 222, St. Paul, MN 55101-5133 <br />Teleph�ne 651-201-7507 Faac 651-297-5259 TT"Y 651-282-6555 <br />Certiftcatian of an On Sale Liauor License, 3.2°lo Liquor license, or Sundav Liquor License <br />Cities and Caunties: You are required by law to complete and sign this form ta certify the issuance of the following liquor <br />license types: 1) City issued an sale intoxicating and Sunday liquor licenses <br />2) City and County issued 3.2°l0 on and offsale malt liquor licenses <br />Name of City ar Coun Issuing Liquor Lice�se �65�;�,{ +�_ License Period Fram: ;� � To: i�3 i ��p�� <br />Circle One: New Lice� License Transfer Suspenszan Revocarion Cancel <br />(former licensee name) (Give dates) <br />�--~'"'.�---�-----�.� <br />License type: (circle all that apply) On Sale Intc�xicatin Sunday L' u 3.2°lo On sale 3.2% �ff Sale <br />Fee(s): On Sale License fee:$�i�33°��Sunday License fee: $�C� 3.2% On Saie fee: $ 3.2°Io Off Sale fee: $ <br />Licensee Name: 1�/ i�(/►' V/�x.l ly'�^� CY� DOB. _ Social Security #� <br />{corporation, partnership, LLC, or Individual} � � <br />Business Trade Name �S 6��.i (�k _�.�,�. �, Business Addr�e s�G�G1,� (i� #16 �� City �bS�,,l�f 1�Q, <br />Zip Code 1��3 County Business Phane�lZ-�j�j-�—LjU$1 Home Phone <br />Home Address _ _ _ _ _ City __ _ „"_ Licensee's MN Tax ID # �� ��i�� ' <br />Licensee's Federal Taae ID #�2 "'��'�1 �� (T°'4PBZY ca1I651-296-6181) <br />{To appiy call IItS 800-829-4933) <br />If above named licensee is a carparat'ron, partnership, az LLC, complete the following for each partner/officer: <br />„ � . ,,, . i � r � <br />Name (First Middle Last) v DpB 8ocial Securitv # <br />(Partner/Qfficer Name (First Middle <br />Partner/Officer Name (First Middle Last) <br />DQB <br />��: <br />Sacial Security # <br />Social Security # <br />Home Address <br />Hame Address <br />Home Addr+ess <br />Intoxicaiing liquor licensees must attach a certificate af Liquar Liability Tnsurance to this form. The insurance certificate <br />must contain al[ of the following: <br />1) Shaw �he exact licensee narne (corporation, partnership, LLC, etc} and business address as shown on the license. <br />2} Cover completely the iicense period set by the local city or county Iicensing autharity as shown on the license. <br />Circle One: (Yes No) During the past yeax has a surnn�ons been issued to the licensee under the Civil Liquar Liability Law? <br />Workers Compensation insurance is also cequired by all licensees: Please complete the fallowing: <br />�"" I ��r� � <br />Warkers Compensation Insurance Company Name: lX� � j'I�i 1�1�1 S�. (s ✓p� Policy #��_ �� 1�? �� � <br />- -' _�T ^ <br />.1 <br />I Certify that this license(s) has been approved in an official meeting by the �averning body of the city or couaty. <br />City Clezk or County Audi.tar Signature Date <br />(title) � <br />On Sale Tntogicating liquor licensees must also purchase a$20 Retailer Buyers Card. Ta obtain the <br />application for the Buyers Card, please cali 651-2U1-7504, ar visit our website at www.dbs.state.mn.us. <br />{Form 9411-12109) <br />