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�� <br />i�., iz:� •• . . . •� <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 <br />Telephone 651-296-6979 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday Liquor License <br />Cities and Counties: You are required by law to complete and sign this forn7 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% oti and off sale malt liquor licenses <br />Name of City or County Issuing LiquorLicense RosP_vi 11 e License Period From: 1 r`1/2006 To: 12/31/2006 <br />A----� May 1, 2 0 0 6 <br />Circle One: New License �.i�•������- = �:� i�Y I��. Ci�I � Odq 1�. L. L. C��k�y��k �������,;� y� � t��.��•;�1� <br />(former licensee name) (Give dates) <br />License type: (circle all that apply) [On Sale Intox� ����la��l,,:� 3.2%On sale 3.2%Off Sale <br />Fee(s}: On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />rrr�_...,y.� .1�'! 1}�1�� <br />LicenseeName: C�VI CY ROSEVILLE, L.L.C. �17,'i� SocialSecurity#_ _ <br />d/b�corporation, partnership, LLC, or Individual) <br />a Courtyard by Marriott Roseville, 2905 Centre Point Drive, Roseville, MN <br />Business Trade Natne Business Address City <br />F�I - b� 7 '�n,r_ � n - � - - � <br />�JLIi�'ii��tJJ.�� ti'�.171'.• i�uiTl$cj% Jiti�!i7t•k�Phone �U�G–J7J–/I�OV RTS.�It'�f71:��11t' — — <br />]���_��rAddress 500 Washington Av����e ������'�1r:ls. MN 55415 � � _ <br />Licensee s MN Tax ID#_ <br />_ . _ _ _ - (To Apply ca11651-296-b12S1) <br />Licensee's Federal Tax Tl� # <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partneriofficer: <br />SEE ATTACHED <br />PartnerJOfficer Name (Fust Middle Last) DOB Social Secwity # Home Address <br />(Partner/Officer Name (First Middle Last) <br />PartnerlOfflcer Name (First Middle Last) <br />I�Z�13 <br />��: <br />Social Secwity # <br />Social Secwity # <br />Home Address <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />mt�st contain all of the following: <br />1) Show the exact licensee nalne (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: t'� �•� �• � L� During the past year has a sui��t�zons been issued to the licensee under t�ie Civil Liquor Liability Law? <br />Workers Compensation Iilsurance is also required bv all licensees: Please complete the following; <br />Workers Compensation Insurance Company Name:. � <br />Policy #_ <br />I Certify that this license(��as been approved in an official meeting by the governing body of the city or county. <br />City Clerk or County Auditor Signature Date <br />(title) <br />On Sale Intoxicating liquor licensees must also purchase a$20 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please ca11651-215-6209, or visit our website at www.dps.state.mn.us. <br />rru:�_� ��� i i a �r�a; <br />