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, <br />����wm���.� <br />i�mk..,�Mx+��.,�„.,M,iFlN.� ��h:«WA� <br />Aie u�aul & Cnq��Rfrem,� £nkoaar�:E::n <br />Mi����esota llepartineilt of Public �afety <br />.�ieol�ol and Gambling Enforcement Division {�.G�I�} <br />444 Cedar Street, Suite 133, St. Pa��, MN 551p1-513.3 <br />Telepl�o��e G51-2Q1-75Q7 �a� bS 1-29'7-5259 TTX 651-282-6555 <br />Certi�cation o� an [�n �ate Li ua�' License 3.2% �.i uor license or �ur�da Li �og• License <br />Cit�es and C`ounties: You are required t�y Iaw ta carr�p�ete az�d sigu tfiis form to certify the issuance of the �oIiowiz�� liquor <br />license types: 1) City issued oi� sale intoxieating and Sua�day 1iq�oz lice��ses <br />2} City ai�d Coutlty iss►zed 3.2% oii aiid oFf'sale n�alt fiq��r Iieei�ses <br />Nar�� af Caty o�� Cou��ty Issuizag Liquar Licez�se T,ie�rlse Period �rom: To: <br />Circle Oi�e: New License License Trai�s%r Sus�e��sioz� Revacatiox� Caz�ceI _ <br />(foG7�7er licensee ��ame) <br />Lice��se iy�e: (circle a[i that a��iy} Oz� Sale �zatoxicating Sunday Liquar 3.2�'/o Qn sate <br />�'ee(s}: 4�a Sale Licez�se fee:� Sunday License %e: � <br />Lice�lsee Naine: DOB <br />{coxporatio�i, �art�iea•s �ip, I.,LC, o�• ]aadividual) <br />(Give dates} <br />3.2% Off SaIe <br />3.2% Ou �ate fee: $ 3,2% Off Sale fee: $ <br />Social Seeurity # <br />Business Trade Nante(-;IZUEr�C=JS i��fs� ,4,vr? C��zrt..�` BusiE�ess AddF�ess �r1� (;5'�v;,�u.l.nfc� /�#t�� City /�v5r t,r�C.z..� <br />�ap Code �5lf Couz�ty �usi��ess Pi�aa�e_t °.. _ .__ t.t Hon�e Phoi�c_ - <br />Ho�a�e Addres� J� <br />-- ���'- <br />L'rcensee's �'ederal Tax ID # ��'U` C7`' <br />(i'0 apply ca31 IRS $00-829-4933) <br />� Licensee's MN Tax � # <br />(To Apply ea3) G51-29G-G181) <br />If a�ove named iicensee is cnrporatioil, partl�ership� nr L�,C, cnmplete �he followi��g for each part��er/o�ficer: <br />�—,— .�+�C , . <br />%� G� 7 � � � w ,_ _ • r — _ —� sa. " ' <br />,.._......�.�.�.�.�-..... . .. <br />Partner/Officer�lan�e (First Mit�dle LaSt) D013 Social Security # �` _..,,..,..�uu«aa <br />(Paatner/0fficer IVamc (First IVFiddle Last) <br />Pai�ine�-/Officer Name {First Middle Last) <br />I��: <br />D013 <br />Social 3ecurity # <br />Social Secur'sty # <br />Hnn1e Address <br />Home Address <br />Iaitox�cating Iiquo�' lice�isees rnust attach a certiticatc af Liquor Liability Tnsura��ce ta ll�is far�n. The insurance cer�;i�cate <br />n�ust ca�atain aII af tt�e �'allawing: <br />i) Sliow the exact Iicensee name {corporatioa�, parl��ersF�i�, �.LC, etc) and E��asiness address as showi� oii t��.e licei�se. <br />2) Caver eon�pletely the Iice�lse period set by the loca] city or caui�ty lice�lsing authority as s�awn oi7 t�ie lice�ise. <br />Circ�e O�ac: (Ye No Du�°iz�g the past year ]�as a sux�����o��s been issued to the Iice�asee u��de�° the Civii Liquor LiabiIiry Law? <br />Workers Co��ipensation Insurance is also required l�y alI licensees: Please con�plete tl�e £ollowing: <br />Wo�'k�rs Can��>ensation I��ssura�ace Com�any Nanie: <br />Palicy � <br />I Ce�'tify tl�at this ►icense(s) has l�een approved i�� ai� of�icial n�eeting by ille governing body of the city or county. <br />City Clerk oz- Cou►�ly Auditar Sig�atu�e Uate <br />� (title) <br />Oz� Sale In�o�icati�xg lig�olr �icet�s�e� musi also purcl�ase ��20 Retaile� Bu�ers Card. To obtain the <br />a�plication for tl�e Btiyers Ca�d, please eall 6S� W215-6�09, or �isit oar website at ����°��.t� �.st�sie.�a�7.Y��. <br />(Por€�a 9D1 t-514G) <br />