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<br />Minn�sota De�art�-�ex�t oi�ublic Safety
<br />Alcoiafll anci Gar�i�linb Eazfo�-cement Dirr�szp� (.4G�D)
<br />444 Cedar �t;reet, Suite 133, St. Pau1, Mi�I �5�01-5133
<br />Telep�oi�e 651-201-7507 Fax 6S 1-297-5259 TTY G51-282-6555
<br />Cerfifiea�ior� of azx On �aie �,i uor �icense 3.2°/> �,i upz ��cense or Suncla�v Li uo� Licerxse
<br />Cities and Counfzes: Yau a�-e requi��ed i�y law io cazn�iete az�d si�,n� this fo1��� ta ce1-tify tl�e isst�az�ce of tl�e followiz�� �ic��.�o��
<br />I�cense ty�aes: 1} City issued oa-� sa�e inla�icatin� a��d Sti��aday liquoi' licei�ses
<br />2) City and CoL€��iy iss�zed 3.�°/Q oz� ax�d o�f sale n�ai� �iqt�or Iicenses
<br />Naine of Crty ox� Couilty Iss��ing Lzq�or l�.,icesase_ Roseville �,iceilse Period �'r��n: To:
<br />Circle One: �ew License Lice�.�se Tz•ansfez• �t�spe��sion Re�ocatio�� Cai�cel
<br />(faa�G��er licensee na�ne) (Give daYes}
<br />Licez�se tYi�e: {circ�e aIi tnat a��lY} On Sal� InPOxicati��g Stznd�y Lic�uo�- �.2"/� C?n sale 3.2% C)ff ��le
<br />�'ee{s}: Oz� Sale Liaense fee:S� Sui�day License fee: �
<br />I,zcensee Nam�: VIC�IRP Res�au�an�s, .T_nc. DOB
<br />(corporation, pa�rt��ersl�ap, S�LC, ar individt�ai}
<br />�.2% On Sale fee: �1.OQ— �.2% Q�'f Sale f�e: �
<br />,-,.-.-..,,, - — ---
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<br />Business Trade Narne ��kers S ar� R� au���-asiness Add��ess ��3 .�1 �i��,z,,,��,� w Cii�r� �n��,_,._..,._,,�
<br />�ap Cnde 55�,�� Co�nty�ss��r Bt�si�less Pho��e_ (��� 1 fi�1..���? Hon�e P�zoxe
<br />Hon�e Address Ci�y Licensee's MN Tax ID �r 536�.761
<br />('�'o Ap��3y cal l 651-2iG-G 18 7 j
<br />Lacei�.see's k'ede�•al Tax TD #
<br />(To appiy call IRS 8fl0-829-�933)
<br />Tf above nained lzcensee zs a eoz-�oratioz�, �ax-t�-�ership, or LLC, co�nplete the �'o1lov�il2�; �or eacl-� �art�ler/of%cer:
<br />�31'�CFei� Viili:�'.r ivamo r �+,r� YIIlR Cnr.ial �e�rih-itV ,*�� .k'i.0171� AC1flt'£:SS
<br />(Pat-hter/OfficPr N�,,,n ��,r=.. ... .
<br />_._.� L?OB
<br />_.�,-,a� .l`r�r.ririfi� �i �OSl2E �C�C�i'CSS
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<br />Social Secur�ty # T3on�e Address
<br />I�3#oxicaiing Iiquo�- Iicensees ��aust attach a ce�-tificate nf Liqunr Liability Tnsura��ce to il7is fo�-��1. T%e izastrrazlce cei-�i�cate
<br />inust coa�tain a11 of the �ol�owiz�a:
<br />1} Slaaw the exaci lice�asee x�ax�-�e (co��oration, pa��hnersl�i�, LLC, etc) a��d business address as sl�orvza oi� tl�e licez�se.
<br />2) Cover co�npletely the lieense �eriod set by #l�e local city or couzai.y �icez�sa�g a�rtl�pz�zty as slzo�vn on tlie l.ice��se.
<br />Circle 4ale: (Yes No} Du�ng the �ast year 1�as a su�7unozas t�ee�� zssued te� fi1�e Jice�asee u�adex tl�e CiviI Li���ar Lia1�il�ty Law?
<br />Wor�cers Coz��ei-�satia�a ���surance is also requia-ed �y a11 licensees: please con�plete tl�e �'oilowiizg:
<br />Worl�ers Co�n��e�asatio�� Ta�surax�ce Co�npai�.y Naine: _�_ o- _ policy ##
<br />I Cst•ti�y f�at tl�is Iicez�se(s) ��as l�een appraved in ai� official 1�zeeti�g by the govez��ing Uady o�ihe ciiy or cnui�ty.
<br />Ciiy Clexlc or Caunty Auditox Sigi�ature Date
<br />(�itl�)
<br />On Sale Intoxieat�ng lic�uar licensees �ust aiso �u�-eT�ase a$20 Re�ailer Buyex-s Card. T� c�btafn t�e
<br />a�pl�cation for the $uyers Ca�-d, piease call 651-215-6209, or visi� ou�• vc�ebsxte at r�vrvr�.���s,s���te;.���.��s.
<br />(Fo�°�x� 9(�11-S/fl�
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