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2015_0406_CCpacket
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2015_0406_CCpacket
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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certification 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 the following liquor <br />license types: 1) City issued on sale intoxicating and Sunday liquor 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 Rosevill.e License Period From: ✓��2� To: �42.-��J' � Z.� 1� <br />Circle One: New License License Transfer esM cy Roseville, LLc Suspension Revocation Cancel <br />(foimer licensee nauie) (Give dates) <br />License type: (circle all that apply) X On Sale Intoxicating XSunday Liquor 3.2% On sale 32°/a Off Sale <br />1,200.00 (includes on sale and sunda � <br />Fee(s): On Sale License fee:$ Sunday License fee: $ 3.�1/o On Sale fee: $ 3.2% Off Sale fee: $ <br />LicenseeName: csM xotel Management, L.L.C. DOBN�A SocialSecurity# N/A <br />(corporation, partnership, LLC, or Individual) <br />BUS1riESS TPaCl2 N2ffi0 Courtyard by Marriott $US1ri0SS E�ddPOSS 2905 Centre Pointe Dri�ty Roseville <br />Roseville <br />Zlp COC1055113 COUrity Ramsey BUS1riESS P110ri0 651-746-8000 I�Ori10 P110ri0 N/A <br />Home Address N/A <br />C1� N/A <br />Licensee's Federal Tax ID # 41-1816815 <br />(To apply call IRS 800-829-4933) <br />Licensee's MN Tax ID # <br />(To Apply call 651-296-6181) <br />If above named licensee is a corporation, partnership, or LLC, complete the followin� for each partner/officer: <br />Gary Sheldon Holmes <br />450 S. Ferndale, Wayzata MN <br />Partner/Officer Name (First Middle Last) Social Security # Home Address 55391 <br />Eugene Michael Bowar 11 White Pine LN, Birchwood Village, MIV <br />(Partner/Officer Name (First Middle Last) Social Securitv # Home Address 5511 D <br />Steven Louis Schlundt 5804 Bryant Lane, Inver Grove Heights <br />Partner/Offcer Name (First Middle Last) Social Security # � 55076 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 �) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br />Workers Compensation Insurance Company Name: Liberty Mutuai Policy ; _ <br />I Certify that this license(s) has been approved in an ofiicial 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 www.dps.state.mn.us. <br />(Form 9011-12/09) <br />
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