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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />445 Minnesota Street, Suite 1600, St. Paul, MN 55101-5133 <br />Telephone 651-201-7525 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday 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 />Sptfwjmmf23/42/31 <br />Name of City or County Issuing Liquor License_________________ License Period From:_____________ To:______________ <br />Hsbojuf!Djuz!Sftubvsbou!Pqf <br />Circle One: New License License Transfer_______________________ Suspension Revocation Cancel _______________ <br />(former licensee name)(Give dates) <br />License type: (check all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale 3.2% Off Sale <br />Fee(s): On Sale License fee:$________ Sunday License fee: $________ 3.2% On Sale fee: $_______3.2% Off Sale fee: $______ <br />Hsbojuf!Djuz-!Jod/ <br />Licensee Name:____________________________________ DOB____________ Social Security #________________________ <br />(corporation, partnership, LLC, or Individual) <br />66224Sbntfz762.31:.4611dpsq!!:63.3:5.2411 <br />Zip Code________ County__________ Business Phone_____________________ Home Phone__________________________ <br />Hsbojuf!Djuz!Gppe!'!Csfxfsz26:6!Ixz!47!X!$2116!!Sptfwjmmf!NO!66224 <br />Business Trade Name____________________________ Business Address______________________ City_________________ <br />94.5829322 <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 />7826287 <br />Home Address City_ <br />Kfggfsz!Kptfqi!Dsjwfmmp <br />Partner/Officer Name (First Middle Home Address <br />Kbnft!Hfsibse!Hjmcfsutpo!!!!!!!!!! <br />Partner/Officer Name (First Middle Home Address <br />Partner/Officer Name (First Middle Last)DOBSocial Security # Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must <br />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 /> 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 />\[vsjdi!Bnfsjdbo!Jot!DpXD!3644728.11 <br />Workers Compensation Insurance Company Name:___________________________ Policy #___________________________ <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 ONLY, must also purchase a $20 Retailer Buyers Card. To <br />obtain the application for the Buyers Card, please call 651-201-7507, or visit our website at www.dps.mn.gov. <br /> <br />