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ll <br />r_�� � <br />�� <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 55101-S133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certiiication of an 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 form to certify the issuance of t11e following liquor I <br />license types: 1) City issued on sale intoxicating and Sunday liquol• licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />Name of City or County Issuing Liquor License �!C� �f,�iLL.� License Period From: To: (,r `���-��'l�' <br />Circle One: ew Licen License Transfer Suspension Revocation Cancel <br />(former licensee name) (Give dates) i <br />License type: (circle all that apply) On Sale <br />Fee(s): On Sale License fee:$ Sunday License fee:'��( <br />�. _ <br />Licensee Name: �- f�� l/1 L- �- �' - DOB <br />(corporation, partnership, LLC, or Individual) <br />Sunday Liquor <br />3.2% On �e 3.2% Off Sale <br />.2% On Sale fee: $ 1 i)'^`,, ���.2% Off Sale fee: $ <br />�`—�- - --�° , <br />Business Trade Name �. jS c. f%/�i3� ��S'<`l Business Address ��2 ���" , �}j�2 iJr ��V City �v,j ��� �Z� <br />Zip Code S� 11-� County � 1� S-.-� "Business Phone �a�/ �� ��'�7 J Home Phone_ _ __ <br />Home Address_ City_ Licensee's MN Tax ID #�/ rj �--� 7��, <br />Licensee's Federal Tax ID #�-� c� � 2j v�.2 ;� ' (To Apply call 651-296-6181) <br />(To apply call IRS 800-829-4933) <br />If above natned licensee is a corporation, parmership, or LLC, complete the following for each nartner/officer: ,. <br />/�-1�1��� x;�t��' , - - , - _ <br />Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />(Partner/OfficerName (First Middle Last) <br />Partner/Oiticer Name (First Middle Last) <br />��C <br />��: <br />Social Security # <br />Social Security # <br />Home Address <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 />Circle One: (Yes No, � During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Workers Compensation lnsurance is also required by all licensees: Please complete the following: <br />Warkers Compensation Insurance Company Name: S��1_ ��� j�oL� ita.�'olicy # �-i� �� c� �, �/ <br />I Certify that this license(s) has been approved in an official 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 call 651-201-7504, or visit our website at ��-��►���-.dps.state.mn.us. <br />(Form 4011-12/09) <br />