Laserfiche WebLink
� ���ce� K� <br />Minnesota Departinent of Public Safety <br />Alcohol and Gambling Enforceinent 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 />Certi�cation 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 tlle issuance of the following liquor <br />license types: 1) City issued on sale intoxicating atld Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />Narne of City or County Issui�lg Liqtior License �t1�t j/ �'L(,� License Period From: � 2-� I-2-� I S To: "�-"�3 i—�1 l.� <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(fonner licensee nauze) (Give dates) <br />License type: (circle all that apply) On Sale Intoxicating <br />Fee(s): On Sale License fee:$ <br />Sunday License fee. $ <br />Sunday Liquor 3.2% On sale 3.2% Off Sale <br />3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />Licensee Naine:_�ir��t�lES'� �r�tJ(,�� d� L,C DOB Social Security #_ <br />(corporation, partnership, LLC, or Individual) <br />X',�7`�3at�',�vi� <br />Business Trade Name����'�,1�,� �f,./,ql �'���M�� Business Address 1%iI k�/�°� � Tf2�'E`� City /�G'.S�u:G�� <br />Zip Code a�//..y County �' Business Phone ��j �,c�� ],G`�� Hoine Phone_ <br />Home Address City Licensee's MN Tax ID #���" % t��./ <br />Licensee's Federal Tax ID# �� �-_��y,� �G� � (To Apply call 651-296-6181) <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />1��� ��yl,�r <br />Partner/Offiaer Nsime (Firs�Middle�,ast) DOB Social Security # Home Address <br />,�%t �1 +,� <br />(Parhier/Officer Name (Fiis� Middl Last) <br />Partner/Officer Nain7e (First Middle Last) <br />��C <br />��: <br />Social Security # <br />Social Security # <br />Hoine Address <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this farm. The insurance certificate <br />must contain all of the following: <br />1) Show the eYact licensee nanle (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Cover coma�letely 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 Insurance is also required by all licensees: Please complete the following: <br />Worlcers Compensation Insurance Compairy Name:_ �� I� h'�v� u� I I ns . Policy #���1 ��z-� �'2-� � <br />I Certify that this license(s) has been approved in �n official meeting by the governing body of the city or county. <br />City Clerlc or County Auditor Signature Date <br />(title) <br />On Sale Int�xicating liquor licensees must also purchase a$20 Retailer Buyers Card. To obtain the <br />application for the Suyers Card, please ca11651-201-7504, or visit our website at www.dps.state.rnn.us. <br />(Form 9011-12/09) <br />