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� <br />�"� <br />,n,F� � ��. � <br />r�;��� <br />....,.n,��� <br />��� <br />Minneso#a Department of Public Safety <br />Aicohol and Gambli�g Enforcement Divisior� (AGED) <br />444 Cedar Street, Suite ] 33, St. Paul, MN 55 i 01-5133 <br />7'elephone 65 i-201-7507 Fax 651-247-5259 'fTY 651-282-6555 <br />Attachment A <br />Certification of an On Sale Liquor Licen,s,e� 3_2% Liquor iieense, or Sund,a,y,.Liquor License <br />Cities and Counties; Yau are rec�uired 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 liquot licenses <br />2) City and Caunty issued 3.2% on and off sale ma�t liquor licenses <br />Name of City or County Essuing �.iquor License � V�� � License Aeriod From: � ���� <br />Circle One: �cen License Transfer Sus �, <br />pcnsi�n Re��cat��n Cancel <br />(former ]icensee name) (Give dates) <br />License type: {circle all #hat apply) On 5ale In€oxicating Sunday Liquar 3.2% On sale 3.2% �ff Sale <br />Fee(s�: On Sale License fee:��'7G�p.�Sunday License fee: $�UO �3.2,°/4 On Sale fee. $ 3.2% Off Sale fee: �` <br />Licensee Name: �i� �Vi��� .�l.r� DOB Social Security # <br />(cor�oration, pamtersl�ip, LLC, or Individual) <br />Busir�ess Trade Na�ne_�, � ' t����j,i.� Business .4ddress W �r�. � City ��..?�� �f � <br />Zip Code�� County �,5� Business Phone�jjr� � ��� Home Phone <br />Home Addre , J Tax iD <br />" {To Apply call 651-296-61 B I) <br />Licensee's Federai Tax ID # <br />{To apply cail IRS 800-829-4933) <br />If ab�e narned licens� iis a carpo�ration, �artnershi�, or�.,L�C,�complete the following fo�r each partner/officer: <br />; i .. . _. <br />Partner/OffcerN�me (�irst Middle �ast <br />(1'anner/Officer Name (First Iviiddlc Last) <br />Partner/01'ticer Name (�'irst Middle Last) <br />�DOB� � <br />��C <br />DOB <br />Social Seturity # � <br />Social SecuriCy # <br />Socia[ 5ecurity # <br />Hame Address � <br />Home Address <br />Hame Address <br />Intoxicating ]iquor licensees must attach a certificate of Liq�or Liability [nsurance to this form. The insurance certifica€e <br />must contain a]] of #1Ze following: <br />1) 5how ihe 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 locai city or county licensing authority as shown an the license. <br />Circle One: (Yes o'� During the past year has a surnmons been issued fo the licensee under the Civil Lic�uor Liability La�v? <br />Workers Campensation Insurance is also required by all 6icensees: Please comp[ete the following: ` _ <br />Workers Compensa�ion Insurance Company Name _ Policy <br />• ' �: <br />[ Certify that rhis license(s} has been approved in an officia] ineeting by the gaverning body of the city or county. <br />Ciky Clerk or Cau.niy Auditor Signature � Date <br />(title) <br />—.d - - v <br />On Sale Intoxicating liquor licensees must aiso purchase a�20 Retailer Suyers Card. Ta obtain the <br />ap�lication for t�e Buyers Card, piease ca11651-201-7504, or visit our �►�ebsife at wvv�v.c��s.state.mn.us. <br />��'o� go r � -srob� <br />