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Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 444 Cedar Street, Suite 222, St. Paul, MN 55101-5133 Tel ephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 Certification of an On Sale Liquor License, 3.2% Liquor license, or Sundav Liquor License Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor license types: 1) City issued on sale intoxicating and Sunday liquor licenses 2)City and County issued 3.2% on and off sale malt liquor licensesName of City or County Issuing Liquor License Roseville LicensePeriodFrom: To: 12-31-2 021------Circle One: New License License Transfer __________ Suspension Revocation Cancel (fonner licensee name) _ ____.,- (Give dates) License type: (circle all that apply) (on __ S_a_l e_I_n-to -x-ic_a_ti _nD G:dayLi� 3.2% On sale 3.2% Off Sale Fee(s): On Sale License fee:$ 5833.30 Sunday License fee: $166.70 3.2% On Sale fee: $ ___ 3.2% Off Sale fee:$ __ Licensee Name: ?i:i:z CA Lu(.[ , v 11 \ :[V'\ c., •DOB NA Social Security # __ N_A ______ _ (corporation, partnership, LLC, or Individual) Business Trade Name V\ "l1 c...... W t(Business Address �S \ �W.� {Jvt, �ity �, l le.Zip Code 'SCSI l '.';, County�� Business Phone (;SI -1 t<¾ --�90't_ Home Phone _______ _Home Address -City __________ Licensee's MN Tax ID# °t.2 14S Licensee's Federal Tax ID# L--l1 --[(.Q. J.. LI C, Y S' (To apply call IRS 800-829-4933) (To Apply call 65 1-296-o 181) If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: ';:)u_, a H-�Cl\l'-L� �...,. Partner/Officer Name (First Middle Last) DOB (Partner/Officer Name (First Middle Last)DOB Partner/Officer Name (First Middle Last)DOB Social Security #Home Address Social Security #Home Address Social Security #Homo Address Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must contain all of the following: 1)Show the exact licensee name ( corporation, partnership, LLC, etc) and business address as shown on the license.2)Cover completely the license period set by the local city or county licensing authority as shown on the license.Circle One: (Yes@ During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law?Workers Compensation Insurance is also required by all licensees: Please complete the following:Workers Compensation Insurance Company Name: "Q"r'YY\ Policy# t../(J !> � 2. 3():>I Certify that this license(s) has been approved in an official meeting by the governing body of the city or county.City Clerk or County Auditor Signature_________________ Date ________ _ (title) On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the application for the Buyers Card, please call 651-201-7504, or visit our website at www.dps.state.mn.us . (Form 9011-I 2/09) Attachment A