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t �;J <br />Alcoho] & �am611naj E�+faroe+mcnl <br />Minnesota Deparhnent of Public Safety <br />Alcol�ol and Gambling �nforcement Division (AGED) <br />444 Cedar Street, Suite 1�3, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 65i-297-5259 TTY b51-282-6555 <br />Certification of an On Sale Liauor License. 3.2% Li,quor license. or Sundav Liquor License <br />Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following Iiquor <br />license types: � City issued on sale intoxicating and Sunday liquor licenses <br />) City and County issued 3.2% on and offsaie malt liquor l�censes <br />Name of City or County Issuing Liquor License l�,�a=�' +)�� License Period Frorn: �(�7� To: �z. C� �(� <br />Circle One: icense License Transfer Suspension Revocation Cancel <br />(former Iicensee name) (Give dates) <br />License rype: (circfe all that apply) O Sh aIe Intoxicat' Sunday Liquor 3.2% On sale 3.2% Off Saie <br />Fee(s): On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee. $ <br />Licensee Nart�e:. �% ��� �U 1�] I`� v�'C7Li�{�-� DOB� � � Sociai Security # F ~ � � � � <br />(corporaiion, partnership, LLC, ar Individua!} <br />Business Trade Name � c -�- Business Address4�`6�- �•�� ���� City_(2U��.v t� 1� <br />Zip Code � i!?� Counry ��,�� �p,,,; Business Phone .�5 1—t--j g�s -- I�,' ZS� Horr�e Phone_ "—' � <br />Home Address <br />� City <br />Licensee's FedEra] Tax ID #__ ,� �-- 1�3 Z�� 3� <br />(To apply calt IRS 800-829-�L933) <br />Licensee's MN Tax ID #.��-tt,¢'&�7�� <br />(To Apply ca11651-296-6181) � <br />�..�l� '3 �� U <br />If above narned licensee is a corporation, partnership, or LLC, complete the following for each partner/o�cer: <br />� -�-� � � �- <br />- - � <br />Partnerlpfficer Na�ne (First Middle Last I)OB Social SecuriCv # Hame Address <br />��-�` � +J P � -- ��,��z.D - . . _ , � , <br />(Partner/Offcer Name (Pirst Middle Last} <br />Partner/Of£icer Name (First Middle Last) <br />��: <br />��: <br />Social Security # <br />Socia! 5ecurity � <br />..,,..ie Address <br />Home Address <br />Intoxicating liyuor licensees must aitach a certificate of Liquor Liability Insurance ta this form. The insurance certificate <br />must cantain all of the following: <br />]) Show the exact licensee nazx�e (corporation, partnership, LLC, etc) and busi�ess address as shown on the license. <br />2) Cover corr�pletel.y the license period set by the local city or county iicensing authority as shown on the license. <br />Circle One: (Yes �) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Warkers Compensation Insurance is alsa required by all licensees: Please complete the foliowing: <br />Workers Compensation Insurance Carr�pany Name�-� Cc� �' oIicy #'� <br />I Certify that this Iicense(s) has been approved in an official meeting by the governir;g body of the city or county. <br />Ci�ty Clerk or County Auditor Signature Date <br />(t�tl�) <br />On SaIe Intoaticating lic�aor licensees m�st also purchase a$20 Retailer Buyers Card. To o��ain the <br />application for the Buyers Card, please call 651-201-7504, or visit our website at www.dns.state.mn.us. <br />(Form 961 t-5106) <br />