Laserfiche WebLink
p �r � <br />.i �wr: <br />Minnesota Depariment of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certi�cation of an On Sale Liquo�• License, 3.2% Liquor license, or Sundap Liquor License <br />Cities and Counties: You are required by law to complete and sign this fortn to certify the issuance of the following liquor <br />license types: 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 />Name of City or County Issuing Liquor License �#�� ����� License Period Froxn: To: <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(former 11Ce17See name� (Give tes <br />License type: (circle a�E tl�at apply) U� .��'_� I n-�o-xiti3<<i�,�. L 3.2°/o On sale 3.2% Off Sale <br />Fee(s): Chl Sale License f��::5 + u� �� Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />LicenseeNa�ne: California Pizza Kitchen, Ine. DOB NIA Social Security # N/A <br />(CA1pOIa110Y1, parl�letSlllp, LI.C, or Individual) <br />854 Roseda1e Center <br />Business Trade Name California pizza f��.���j. Business Address �����' 1C1� City ��s�vi TT� <br />Zip Code 55113 County Ramsey Business Phone not vet �pp�, �inme Phone 310-342-5000 <br />T-�orne Address 6053 W, Centur Bl Vd. City L�� Anqeles Licensee's MN Tax 1D # 4381636 <br />1 � Floor �ro�i,ia�:�u6si-a96-6isi� <br />Licensee's Federal Tax 1D # �r�- � � � _ <br />(Toapply cai! [R$ 800-829-4933) <br />ff above aaazned licensee is a corporation, partnership, or LLC, complete the following for each pa�t�-��rloi�'icer: <br />See attached <br />E'artnerl0fficer Name (�irst Middla Last) DOB Social Security # EL� Addtess <br />(Partner/Qf%cerName (F1rStMlddle �,ast} DOB 5ocia[ SeCLIlily �� H�lle Addt�SS <br />PaitnerlOfficer't�iaine (FIt'StMiddle Last) DOB Social SeCiully # <br />�� - � � �s=,� <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this forir�. The insurance certificate <br />must contain all of tl�e following: <br />i} Show tlae exact licensee name (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 summons been issued to the licer�se� under the Civil Liquor Liability Law'? <br />Workers Compensation Insurance is also required by all licensees: Please coinplete the following: <br />Workers compensation lnsurance Company NaEne: Zurich Amer. Insur. Co. Policy # GL02347034-OS <br />1 Certify that this license(s} has been approved in an official meeting by the governing body of the city or county. <br />City Clerk or County Auditor Signature Date <br />On Sale Intoxicatin� liquor licensees must also purchase a$20 Retailer Buyers Card. To obtain the <br />application for the �uyers Card, please calX 651-215-6209, or visit our webs�te at r��r�rr�v.r��s.state.���.u�. <br />(Form 9011-5/0� <br />