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� � rti� � <br />� �. �� <br />`�z.��:� <br />��;.��.,.,,>�..�,.:.r.,.� <br />� ' �� <br />Minnesota Department of Pu�lic Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite I33, St. Paul, MN 55101-5133 <br />Telephone 651-2Q1-75Q7 Fax 651-297-5259 TTY 651-2$2-6555 <br />Attachment A <br />Certification of an On Sale Li uar License 3.2% Li uor license or Sunda Li uar License <br />Cities and Caunties: You are required by ]aw to complete and sigr� this form to certify the issuance of the following ]iquor <br />license types: 1) City issued on sale intoxicating and Sunday ]iquor licenses <br />2) City and County issued 3.2% on and off sale ma�t liquor licenses <br />Name of City or Count.y Issuing Liquor License �1! �� �— License Period FroEn: � ���t <br />�. <br />Circle One: icen License Transfer Suspension Revocation Cance! <br />(former licensee name) (C�ive datcs) <br />License type: (circ[e all that app]y) On 5ale Intoxicaiing Sunday Liquor 3.2% On sale <br />Fee(s�: On Sale License fee:$`7�p.�Sunday License fee: � aG1'�_�_,�3.2,%Qn Sale fee; � <br />Licensee Name:�� �.�VI ��'�- � DOB Social Security �_ <br />(cor�aration, partnership, Li�C, or ]ndividual) <br />3.2°/a Off Sale <br />3.2% Off Sale fee: $� <br />Business Trade Name ��� i���, ,i.t,�_ Business Address 1� I�[. � City ���j ���_ <br />Zip Code�� County �,�� Business Phone_� j� � �� Home Phone <br />, �-- � <br />Home Addre ,_ J Tax ID <br />" � (To App1y cal I 651-296-6 ] 81) <br />Lice�see's Fede�ral Tax ID # _ . __ _ � _ <br />(7o apply call IR5 800-829-4933) mm <br />If ab�o�ve named licen.s� iis a corpor�ation, partnershi�, or�,L�complete the following fo�r each partner/officer: <br />� <br />PartnerlQf�cer Name (Firsc Middle Lasi �DOB� �� Social Securiry #� � Hoine Address <br />(I'artner10fficer Name (Firs� Middia Lasi) <br />Par[ner/OfficerName (Pirst �vIiddle La�t) <br />DOB <br />l�. <br />Social Securily # <br />Social $ccurity � <br />Hame Address <br />Home Addres5 <br />[ntoxicating liquor licensees �nust attactt a cert.ificate of Liquor Liability insurance to this form. The insurance certificate <br />must contain all of the fol lowing: <br />1) 5how the exaci licensee name (corporatian, parinership, LLC, etc} and business address as shown on the ]icense. <br />2) Cover cam�lete[y the ]icense period set by the local city or county iicensing authority as shown on the license. <br />Circle One: (Yes o� During the past year has a summons been issued to the licensee under the Civi] Liquor Liability La.w? <br />VJorkers Com�ensation Insurance is also required by aii licensees: Please complete the following: �, _. <br />�, <br />Worl�ers Compensation ]nsurance Company Name _ Policy _. _ ,�_ _ , _,,, _ - _ � <br />� �: <br />I Certify that this license(s) has been approved in an afficia[ meeting by the governing body of thz city or county. <br />City Clerk or County Auditar Signature � Date <br />(tit�c) <br />On 5ale Intoxicating liquor licensees must also purchase a$20 Retailer Buyers Card. To obtain the <br />a�plication. far the Buyers Card, please call 651-2D1-750�, or r�isrt our website at www.dps.state.mn.us. <br />{Form 901�-5/06) <br />P� <br />