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Minnesota De�art�zaeni of Pu.biic Safety <br />AicuhoE anci Ga�bling Enforcetuent �3iv�sion (A���l) <br />4� Cedar Si�e�t, Suzte 133, S�. I'a�a.l, MN S5I41-S133 <br />Te�ephQne fi51-201-75(37 Fax 651-297-5259 TTY 651-282-6555 <br />ertification of au On �Sais Isi �or ��cense 3.2°/a Li uax �icense or Sunda L'z uor �.%ce�s� <br />Cities at��i Count�es: Yau az�e required (�y law to aamplete and sign t�ZZS form to oertify the issuanee of Che fflila�ing tiquor <br />Eicense iyp�s: 1) City issued on sale: i:ntt�x'rcating aud Sttt�day liquor licenses <br />2) City and Couzziy issueci 3.2°/a an asid of�'sale malt Iiquor iicens�s <br />I�tazne of City ar Cow�ty Issuing L€q�or License D�.a�'i ��� �iaense Pariod I'rs�m: To: l�e � 3 I��° �� <br />Gi�'c�e One: New Lscense �.xeense Tra��sf�r Suspension Revocation Cattccl <br />(farmer licensce name) (Give dates} <br />Linease type: (circle all tt�at app1Y) On 5ale Tn€c��cicat%n Sunday �.�q�or 3.2% �n saie 3.2% 4ff Sa(e <br />�es(s): Qn Sate Lic��se fee:$ pP3A.�k�Sw�day License fes: � o�DO• ��4 3.2°to fln Sale fee: � 3.2°/a Of�' Sale fee: $ <br />Lieensee Name: �i�., il�ri �'� �.� DOB _ Svcial Seeurity # <br />(corporation, ers'lu'p, L.I.C, ar Fndividualj <br />Bus�ess Tsade Name �f%'',S �.�'��� a�' �' ........�. Busin�ss Addz'ess �� � �G�',�•,���,citY ��}fi'1 ���. <br />Zi� Code 11 County" ��� �usiness Phone�,,�f ` ��� �- .� �fe� Hazne �'�Qaae <br />Home Addz�ess C�ty _ , Licensee's MN Tax �i �fi ��'..�+�.�� <br />{i'o Appiy ca3E 651-296-G181) <br />Lieensee's Federal ']'ax ii� � o��r - �1���J�� <br />tro a�P�y osrt �z�s soa�az�-a�a3� <br />if abn�v� nam.ed licensee is a corporation, partners�i�, t�r �.LC, coz�piete the follawing for each partner/c��acu�; <br />. . . .''�Id .!v <br />L CrG� ,��^t�"t�. � . <br />Pa erlflfficer �Vame irst Middle Last) . DO�S . Social Secuntv #� �^mP A�ldr�ss .�. � . <br />M��+ FI'` f�f�ff�SG . . • __,, _... ; F ''-,—�—, � _... �� t`�F � _ ' r <br />._.. . �.,.�, �. : . F <br />(Partner/d€�'icer Narne (First �+tiddle Lest) �OB 3naiat Securiiy # r.v, ,,.� �iame A��res� ��, ,� . <br />��.e�^ . p /.� � � A <br />�t[.t�i J, ��Ui#t��,�/i �: ` �_ , ,::.. .._'"-"r �'-•'- y`---:�F:_ <br />PartnerfOf�oerName (First Middte Last} A�B Sociai 5ecarity # T�ame Address <br />�ntoxicating Iiqunr Iicensees must attach a certi�ca�e o�L'aquor Z.iability Iusuranee to this form. The insurance certi�cate <br />znusC coutarn alI of the �ollawing: <br />I) Show �e exaet Iicensee narn� (aozporatinn, parhaerslaip, LLC, eic) and b�asiness address as shown on tl�e lice�s�. <br />2) �over cornpletcly tlae iicense periud set by �b.e iocaf city nr cat�z�ty ]icansang au#hority as shawn o� the licerzse. <br />Cirele One: (`Y�es � buring �kze past yeat has a sutnmflns been iss�.ed to ti�e lioensee under f�e Civil Liquor Liab�[ity �,aw? <br />'Workers Go�pensation Insurance is also required lay ali tieeusees: �'leas� co��plete the following: <br />Worlters Cotnpeusaiion Insuranee Company Name: Policy # <br />I Cez�zfy that ihis l�cense(s) has been approved in ar� oif ciai zn�eetang by the governing body bf 1h� city ar cpunty. <br />City C1erk or Ca�xtty Auditor Signat�ure D�te <br />(��a) <br />U� Sa�� �ntoxicai�ng �quor licenseas rnust also pt�rchas� a$ZO Retai�er I3�y�rs Card. To abtain �e <br />a��lieatian fa� ibe Bn�ers Card, please caR 651-Z15-6209, or visit a�r vvebsi�e a� ��-���v.c� s.state.znn.us. <br />(Form 901i-SIDG} <br />