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Alcohol & Gamblint Enforcemtn t <br />Minnesota Depa11ment of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 55 IO I -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 Sunday Liquor License <br />Cities and Counties: <br />license types:You are required by law to complete and sign this form to ce1tify the issuance of the following liquor <br />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 Issui ng Liquor License Roseville/Ramsey License Period From: ______ To: <br />Circle O�e License Transfer ___________ Suspension Revocation Cancel"f <br />� (former licensee name) (Give dates) <br />License type: (circle all that apply) �le Intoxi� �nday Li� 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 />Licensee Name: PAR365, LLC DOB NIA Social Security #----------------------------------(corporation, partnership, LLC, or Individual) <br />Business Trade Name Business Address 2655 Patton Road------------- <br />Licensee's Federal Tax ID# 88-0906315-------------(To apply call IRS 800-829-4933) <br />If above named licensee is a corporation, partne h · <br />Mercedes McFarland Jackson <br />Partner/Officer Name (First Middle Last)Thomas Ray Jackson Jr <br />(Partner/Officer Name (First Middle Last) <br />Partner/Officer Name (first Middle Last) <br />DOB <br />DOB <br />LLC 1 t th D II fi <br />Social Security # <br />Social Security # <br />(To Apply call 651-296-6181] <br />h t /ffi <br />Home Address <br />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 fo llowing: <br />I)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 li cense. <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 Insuranc e is also required by all licensees: Please complete the following: <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 ________ _(title) <br />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. <br />(Form 901 1-12/09) <br />Attachment A