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';�t � �(�w��`� <br />t�3" , <br />, <br />,�� � �s �,< <br />� <br />� .. w�y . � -�..:: <br />:,�,. ....... � <br />���.�..�«, :��: <br />Mir�-iesata Departmen� af �'�viic Safety <br />Alcohol and Gazza�7li�xg �nf'arceznent Divzsioi� (AGED) <br />444 Cedar Str-eet, Suite 133, �t. �'aul, MN 55141-5133 <br />Tele�ho��e 651-201-7SQ7 �ax 651-297-5259 TTY G5J-2&2-6SS5 <br />Certificatior� of �n �n Sa1e Li uo�� Licet�se. 3.2% Li uo�- Iicerzse or Suz�cla Li t�oz- � �icense <br />Cities and Co��ties: You are rec�uirec� by �aw ta co�n�a�et� and sigaa tk�is foz-m t€a ceriify the issuaszce of the �'ollowiza� lic��.ior <br />license �y�es: 1) City issued on sale zr�toxicaiin� a��d Sunday lic�uor licenses <br />2) Cify and County iss��d 3.2�/0 on and off sale �alt li��or lic�z�ses <br />Nazne of Cit� ar Caun�'y Tssuing �,iquar Licei�se Roseva.ile Lic�nse P�x-ioci Fxom: To: <br />Cia-cle Onc: New L�cense Lic��zse Transfer Sus�ellsio�� Revocation Cancel <br />(foa-�a�er licensee j�aine) (Give dates) <br />T�icei�se t��e: (ci1°cle all t�zat a�ply) On Sale Inioxicatin� �Su�iday Lac��oz� 3.2% Oz-� sa�e 3.2% �ff Sale <br />�'ee(s): 4n Sale Lice��se fee:� ,S�rzday Liee�s� fee: $_ 3.2% (�n Sale �ee: $1�70— 3.2°/u Qf� Sale �'ec: �--- <br />FEIN <br />Licensee Name: V�CORP Restau�ants �:�.. Da� ���i�� 84-0511072 <br />(eorporatian, �aitnersi�ip, LLC, or Individual) <br />BLlsi��ess `�'rade Nair�e Baker� 5c�uaxe ftestauran��siness Address Cit�_ R�,���„ � � P .�� �f <br />Zi� Code ,55 I13_ Co���iy Ram��v� Busi�-�ess �'hor�e f�51! H37 —��?�_ __ Hnrric Pl�oile <br />Hon�e Addz�ess Ciiy Liee��see's MN "I'ax �D � 536176�._�_ <br />(To App1y cai! 651-29G-G181} <br />Lice��see's Fedez�a] �'a� ID # 84-0511072 <br />(To apply call IRS 800-829-4933) <br />Tf aba�ve nazned licez�see xs a ca��oration, }�artnersl�i�, or L3 C, com�lete the follovving �or eacl7 �artnerlof�cer: <br />Ke�r�.eth i.,. Ke e�' <br />Parta�et�/Qf�cer 1�la�ne (Firs; Middl.e S�ast) L�10B Socia3 Security # Hoi�ae Add��ess <br />A�-�.Y�ony ,�. Carra�� <br />(�'ar�nezlOfficer Na7ne (First Middls Last) <br />T.�mothv �'. Casev _ <br />Parti�ci°/Officer NanZC (First Middle Last) <br />r�:� <br />L��� <br />Social Security # <br />Social 5ecurity � <br />�-Ia���e Add��ess <br />�Iome Adda�ss <br />In.toxicatang liquor licen.s�es i�lusf a�iac%� a cez�ificate o�Liquor LiaUility Insux-a��ce to tl�as for�n. Tl�e i�1su��ai�ce cez-�i�cate <br />Znust contair� a11 of t�e fotIowing: <br />1) Show t�ie exact licensee i�ai�le {cozporatinia, partnershi}�, LLC, etc) and �usiness address as s�io�an or� tlae lice��se. <br />2) Cover com�leie�y the lzcense pe��iod set �y tlae lc�cal city ar co�.uity licez�s�ng at�tl�oi°ity as sllow�a on ihe liceizse. <br />Cire�c On�: (X�s No) During the �ast yea�� l�as a suz��noz�s been issued to th� license� ui�dez- tlac Civil Lic�uor Lia�ality Law? <br />Wazl�ers Ca����ensatioi� Ti�suraazc� is also xeq��ired by a111icensees: �'lease cozz�plete tl�e fal�awi��g: <br />Warkers �oax��ensation Insurar�ce Co��pan� Na�ne: �'ederal Insurance Ca. Poticy �f 71603777 <br />� Cez-tz�y t?zat tl��s iicez�se(s} �as �eea7 a��roved in an o�ficial z�eet�x�g by tlae govex-z�ing body of tha city or coL�i�ty <br />City Clerl� ax Ca�nty Auditor �ignature Date <br />(title) <br />4n Sale �nto�icating �ic�tror licensees zx►ust also purcbase a$ZO Retailer Buye�-s Gard. Ta obta�� i�e <br />ap�lieaiion �'or �he �3uye�-s Cai'd, please call G51-215-6209, o�� visit our welasrte a� ��v��•��-�r.��,�,si��c,.rai2�.��.s. <br />(�'on� Jfl i t -SIffG) <br />