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� <br />��� <br />� ��� <br />�� <br />Minnesoia DeparimenC of Publia Safety <br />Alcohol �.t�d G�nibling Etifarce�nent T7ivision (AGED) <br />44�} Ceciar Street, Suite 1�,i, St. Paul., R�N 5� I a I',� I.;3 <br />Telepho�}e65�-201-7507 Pa�G�]-?97-5259 T'I'Yb�]-2S2-G555 <br />Attachment A <br />Certification of an On Sale Liquor License, 3.2% T,iquor iicense, or Snndav Liquor License <br />Cities and Counties: You are requirecf by l:��v to ccimplete and si�n ti�rs Form ta certit}� the i5s�iance of the follo4��ing lit�uor <br />license rypes: I) City isst���l or� sale iiitoxicatii�g and Sunday liquor ]ic�nses <br />2} Ci[y and Coui�ty issued �.2% on anci offsale �ti.alt liquar licenses <br />�ame of City or County Issuing Liquor Licens� Roseville Licerlse F'eriod FCOm.: 1/1/20(39 To: �Z/31./�009 <br />Gircle One: Ne�i� License License Transf�er S�ispensian Revocation Cance] <br />(formcr liccnsec namc} (Give dales) <br />E_icense type: (circie al] that apply) Oii Salc l�ttoxicatin� Sunday Liqupr 32°/u O�t�sa—]e� �,2% Off Sale <br />Fee(s): On Sale License fee:$ S�[nday License fee: $ 3.2% On SaJe fee: �.2% Off Sale fee: � <br />LICEIlSC� Nallle:- Sma�shburger Acquis.ition-h7inneapo].is, i,i,� p��j__ �OClB�. S2Cli1']L'� i� <br />f corpoi-aLiohi, parinership, 1.,LC, or inelividu�l) <br />I3usii.sess "i`r°ade iVaEr�e Smashburger Busiizess Address21aa N, SnelZing Ave. �j� Rdsevi�le <br />Suite 65 A <br />Gip Code ��113 Co�uicy Rarrtsey Business Photle �sizJ 802-1095 TemporaryI-�ome Phonel <br />H��ne Adeiress I , [ icer�see'S MN 'Cax.1D # <br />� (To Apply cakl G51-24G-6191) <br />Licensee'S Fe erad ! 1'ax fD �# <br />(1'o apply call IC'.S &J6-8i9-;933) <br />if abave ��amed licet�see is a cor}�oration, pairtnership; or C,�.C; co7i7ple[e tlie fol.lowing for eacii partnerlofficer. <br />T'artFicr/OFficer Name (f�ir5l A�tidcJle Las.t.) QOk� 5ocial' Securiiti: # "' ine Address <br />(I'aric�er/Offcez' idarne (�irst h�liddle L�s;t) <br />f'arlilerlQfGcer NAn�e {rirst M1tiddfe Last} <br />DQR <br />DO$ <br />Sucia) Security # <br />Sacial Security # <br />HomC Nclul�css <br />Ho,s�e Address <br />]nioxicating lic�ui�r 3icensees miisl arlach a cer(iPicate of Liqiior L,iability lnsurai�ce to t�is for�i7, The insurance cerfificate <br />m1�st C�i�taip all af d�e foll�4vitig: <br />l) Sho�t� the cxact 1'sceitsee name (eorporation, �Sartiiership, LLG, etc) anc� business address as shown. on the Iicense. <br />2} Cover completely ttte iieense pzriod set b; the ]oca] city or coui�.ty lic,ensing autfiarit}� as show� on the ]icense. <br />Gircle One: (Yes No Durin� the past ye�r has a sui:itimons becn :ssued to the [icea�see ander the Civil [,iqu.or Lia.bility I,a�v? <br />Workers Co�n�ensation insuranc� is alsa rec�uired 6�� al] ]icensees: P9'ease complete tlte Following: <br />�'�ur�ers Compensatinn. Insurance Contpan}` Na121e: �'raveler's z:,gura�,�e pp��Cy �f <br />I Ce�ti S�y that this license(s} has been app3-oved in an officia] n�eeTing by tl�� bouerriing body of tlie city or county. <br />City C1e�•k or Count}= Audiior Signat�re Dat� <br />(i[tle} - <br />�yi Sale Intoxicatin� liquor l;cens�es rnust aiso pr�rchase a$Zb l�etaiJer 13uyers Card, To obtain tlie <br />A����lic�tior� for the Buye�-s Carcl, �ilease ca�l 651-201-75Ud, ar vrsit our �vebs%te �tt �r«��V.(�E)s.stafe:r��t�.i�s. <br />(i'arn� 901.I-5106) <br />