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��� � <br />,�. <br />Minnesota Department of Public Safety <br />Alcohol and Gambling EnforcementDivision (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN 5S 1 � I-5 � 33 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certitication of an On Sale Lipuor License, 32 % Lipuor license, or Snndav Lipuor License <br />Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor <br />licensetypes: 1} City issued on sale intoxicating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />R���walle ,'�� <br />Name of City or County Issuing Liquor License License Period From: Y�r %v'7 To: ' � 3 r �s � <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(former licensee name) (Give dates) <br />r---_,__ -_i —� <br />License type: (circle all that apply) On Sale �ntoa�i�� ' �1a��j�' Li�[Ifi� 3.2% �;. ��� , 3.2% �tT �il�- <br />�`ee(s}: On Sale License fe� �� ;' ��� {� Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />�.,icen�e� Na�ne: California Pizza Kitchen, Inc. DOB NIA Social Security #_ <br />(corparation, partnership, LLC, �t'Individual) <br />854 Rasedal e Centet <br />BusinessTradeName CalifqY`�id P1zza K-jt_e11e� BusinessAddress SP���' ���� <br />n <br />City Rosevi 11 e <br />Zip Code 55113 County RamseY Business Phone not yet Co�it1, Home Phone 310-342-5000 <br />k-�omeAddress 6053 W, Centur.Y Blvd. City L��� Anaeles Licensee's MNTaxID# 4381636 <br />� OOT (To Apply caii 681-296-6181) <br />Licensee's Federal Tax ID# 35—�0�?� ,,�,,, ___� <br />(To apply call fRS 80�-829-A933} <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each �art��er/of�cer: <br />See attached <br />�ar�nerl�fficerName (First Middle Last) DOB Social Security # Home Address <br />(Par�FierlOfficer Name (First Middle Last) <br />paCkqer/Qf�"jCer Name (First Middle Last) <br />DOB Social Security # <br />DOB Social Security # <br />Home Address <br />Home Address <br />Intoxicating liquor licensees must attach a certi�cate of Liquor Liability Insurance to this form. The insurance certi�cate <br />must contain all of the following: <br />1) Show the exact licensee ��a�ne (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license <br />Circle One: (Yes No) During the past year has a su�n�nons been issued to the licensee under the Civil Liquor Liability Law? <br />Worlcers Compensation Insurance is also required by alI licensees: Please complete the following: <br />Worlcers Compensation Insurance Company Name: ZuT1Ch Amet'. InSUT. ��. Policy #��-OZ��iO3�-(i� <br />I Certify that this [icense(s) has been approved in an official meeting by the governing body of the city or county. <br />City Clerlc or County Auditor Signature Date <br />(title) <br />On SaleL�re�xFraRirrg liquor licensees mustalso purchase a$20 Retailer Buyers Card. To obtain the <br />a��aiu�tuao fur �h� &uyers Card, please call 651-215-6209, or visit our r�vebsite at vvr„vw.di�s.state.t�€zn,us, <br />(Form 9011-5106} <br />