Laserfiche WebLink
. 1, ' Attachment A <br />�� �..�' <br />Alcohol E, G�etbling E�nturcemeni �. <br />Mimlesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 5510]-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certi�cation oPan On Sale Liquor License, 3 2% Liquor license, or Sundav Liquor License <br />Cities and Counties: You are required by law to complete and sign this farm to certify the issuance of the following liquor ; <br />license types: 1) City issued on sale i�ltoxicating and Suilday liquor licenses ' <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />Name of Cit� �r C'ountv Issuing Li uor License Roseville License Period From: �`j� U�&..i CP.._,a To: � G-� � I j��l� I� <br />Circle One� lvew Licens�l License Transfe t� V� l� ' �ll$uspension Revocation Cancel <br />(former licensee name) (Give dates) <br />License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale <br />Fee(s): On Sale License fee:$ Suiiday License fee: $ 3.2% On Sale fee: $ <br />Diamond Lake 1994 LLC DOB Social Securi # <br />Licensee Name: �' - <br />(corporation, partnership, LLC, or Individual) <br />Business Trade Name Cub Foods Business Address 12 01 Larpenteur <br />Zip Code 5 5113 County Rams ey Business Phone 6 51 / 4 8 8-18 2 5 <br />Home Address N�A City N/A <br />Licensee's Federal Tax ID # 41-17 9 5 3 8 3 <br />(To apply call IRS 800-829-4933) <br />.2% Off Sale <br />3.2% Off Sale fee: $ 3 0. 0 0 <br />City Roseville <br />Home Phone N /A <br />Licensee's MN Tax ID # � $ 2 � � � � <br />(To Apply call 651-296-6181) <br />If above named licensee is a corporation, partnersllip, or LLC, complete the following for each partner/officer: <br />Please see attached List of Officers <br />Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />(P� ner/Officer Name (First Middle Last) <br />Partner/nf�cer Name (First Middle Last) <br />��C <br />��: <br />Social Security # <br />Social Security # <br />Home Address <br />Home Address <br />_ - -- _---- — - <br />---- ---- -- <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability I�isura�ice to this form. T e insurance certi icate <br />must contain all of the following: <br />1) Sl�ow t11e 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 />Circle One: (Yes N��During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />See attached Violation List <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br />Workers Compensation Insurance Company Name:SFM Insurance Policy # 9592 • 521 <br />I Certify that this license(s) has been approved in an officia] meeting by the governing body of the city or county. <br />City Clerk or County Auditor Signature Date <br />(title) <br />On Sale Intoxicating liquor licensees must also purchase a$20 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please ca11651-201-7504, or visit our website at v�v�w.d�as.�i�rt�.mn,�s. <br />(Porm 9011-12/09) <br />