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�a���� <br />Minrsesota Deparlment of Public Safety <br />Alcol�ol and G�mblir�g �nforcernent Division (AG�D) <br />�4� Cedar 5treei, Suite i», 5t. Pai�l, 2�9N SS101=513� <br />Telephor�e 6at-201-7�07 Pax �51-297-52�9 TTY 651-282-6555 <br />Certific�tian af an On 5ale L't nbr i..icense 3.2% Li i�or license or Sunda Li uar Liceirse <br />Cities and Counfies: Ya�i are requireci b)r ]a�v to complete and. sion thi.S Foria� to certify tlte issuance of�the ialla�ving ]it�uor <br />license types: 1) CitY issued oii sale irito�icati�ig a�id Suittlay liquor ]icer»es <br />2} City �nd County isstred 3.2°/u an ar�d aff sale lnalT liquor licenses <br />Name of City or Cou�Ity Issuing Liquor License Roseville License Period F�`om:__7_f 1/2009 To: 12 f�' 1,/2pOg <br />Citcl.e One: �e�v License License Transfer S�35pens'ton �evocatiari Car�cel <br />(formcr liccn;�c nanic�} (Cive da�es) <br />�� <br />[.icense t}'pe: (ci.rcle aEl t]lat a�ply} On Sale lnt�xicating 5u3iday Liquor 3.2°/a O�i.sale �.2% Off Sale <br />I=ee(s): On SaCe Lice�ise fee:$ Sunday Licer�se fee: � 3.2°/4 On Sale fee: 3.2% Of� Sale fee: � <br />LICEt15e� Na11lE: Smashburg:er ACqUi51ti4n-M�nned��0115, �LC pOE 5ocial Secu�•iry # <br />(co:paratian, paitnership, �.,[_C, or tndividual) <br />I3�isiness"fradeT�laE�7e Smashburger 13usiizessR.t�dress�loo i�, s«ei�s,�� a�e. G��, Rosevil�e <br />Snite 65 A <br />ZipCotle55J.13 Coui�ty�amsey Busii�essPl7c�ne ivi2J_0�Z-1095 TemPorazYl-IainePhnne i303) 633--1500 <br />1"�QiTle ��ClE�CeS$ 15i.5 Araparoe SC. Towzr One, (�lt�' Der.�ver, Cq AJ202 �,1Cei15�e'S M� �a}�. 1Li # <br />loth �'loo: (To apply call GSI-24G-Gl91} <br />Licensee's F'edernl 'f��x 11� �# <br />('Co apply calf IRS &00-9_9-44a3) <br />If abave i3amed. licensee is a co�•poration, partn.ersE�ip,. or LLC; complete Ehe followii7g for eacE1 paiti�er/officer: <br />i'arGncr/Officer M1�ame (Firsi. A�li[ldl� ),esl} �)013 Soci�] SecUriF)� # " r�ic Address <br />�P�rtnerlOffices'�1ame (Pia�sllvlickdfeL.a;t) <br />ParfnerlQfTiC2r Nante (Firsi h4iddle l,ast} <br />D0�3 <br />L708 <br />Social Securit�� # <br />Sc�cial Secririt}'r <br />l�iomc r�❑uro5s <br />Ho�„e Address <br />Intoxic�ting liyuor 3icensee.s must a1€ach :� cer(i(ical:e of Liquor Liability lnsti�ance to this form. The insurance ce�TifielCe <br />rnust caiit�in a3l tif the �oliotiving: <br />l) Sliow the e�act ]icensee name (corparation; partiierslii�, LLC, etc) a�id business address as sho�vn on the license. <br />2} Cover con�pletely the ]icer�se period set by the local. city or cour�ty Iicensing autEiarity as sho��n on th.e license. <br />Circle Or�e: {Ye�s No [�uring t�he past year has a summons been issued to the licensee ur�der the �ivil Liq�uof Liabit�ity La��? <br />1Vorkers Compensation Insurance is also required by all licensees: Please cantplete T��e Followir�g: <br />1�Vorkers Com�sens�tion [nsurat7ce Company hla��le: Tra�Qler�S Insui�an�e �'olicy #_ <br />I Cec-tify tliat this ]i�ense(s} has been a,pproved in an official n�eetin� by the go�erning body of the city or coun[y. <br />C'rty Clerk or Coiinty Auditor Signature Date <br />�tiLle.) - <br />On Sale Intoxicatin� iiqunr liee��sees must also }�tirchase a$ZU Itetailer Buyers Card. Ta obtain tl�e <br />a���siitatio�� for tlie Buyer�s Carcl; ��lease call f�51-20� -7504, or v'isit aur we�sife :�t ������v:clps.4#ate;m���,us. <br />(I�ocn� 90l 1-51p6} <br />