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�;. <br />�'' � <br />� � ;� � <br />AIC+1'hpl & GdmSliag EniorCnmenf <br />Minnesota Deparrinent of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar St�eet, 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 corriplete and sign this for�n 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 �S�,ila t� License Period From: � r �1 � I> To: �2. '3l ��.n <br />Circle One: ew License License Transfer 5uspension Revocation Cancel <br />(fotmer liceiisee name) (Give dates) <br />--0�:. �.__ � <br />License type: (circle all that apply) On Sale Intoxicatin di a_ v Liq��.�3.2% On sale 3.2% Off Sale <br />•--_.___._.�_..��. <br />Fee(s): On Sale License fee:$� �i��,.if,"1 Sunday License fee: $�� 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />Licensee Name: �, �r 2.���. �-���. ��lS ��� '� DOB Social Security # <br />(corporation,�rtnership, LLC, or lndividual) <br />Business Trade Name �c1 (,G ^ _Business Address r%ig�j� �V�[�vuq .t�vvr(3UCity K:��.�U�Z�.�. <br />Zip Code �Gj� (� County_ �'��� Business Phone (QS—i -�'�i L1 i� Home Phone <br />Home Address City Licensee's MN Tax ID #�.7� `� 1�';� <br />�fl� (To Apply ca11 65 1-296-61 8 1) <br />Licensee's Federal Tax ID # � � " d �!' � `7 � �7 � <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a coiporation, partnership, or LLC, complete the following for each partner/officer: <br />Name (First Middle Last) <br />Name (First Middle Last) <br />��: <br />��: <br />Social Security <br />Social Security # <br />Address <br />Home Address <br />Partner/Officer Name (First N�iddle Last) DOB Social Security # Home Address <br />�� �� ��� <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this fonn. The insurance certi�cate <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 o) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Worlcers Compensation Insurance is also required by all licensees: Please complete the following: <br />Worlcers Compensation Insurance Company Name: � � Policy # � ��j �C . �Q� <br />I Certify that this license(s) has been approved in an official ineeting 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 wvwv.dps.state.mn.us. <br />(Fonn 9011-12/09) <br />