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w � <br />. �.h <br />. _ �;.� <br />r � <br />'}k: vtir-_��i�t.,:.. <br />� ------..._..� <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St. Paul, M� 55101-5133 <br />Telephone651-296-6979 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of an On Sale Lic�uor License, 3.2% Lic�uor license, or Sur�dav Liauor License <br />Cities and Counties: You are required by law to complete and sign this form to certify the issuance of tk�e following liquor <br />license types: 1) City issued on sale into�cating 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 From: "` j� �� To: '�� ���� <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(£onner licensee name) (Give dates) <br />License type: (circle all that apply) On Sale Into�cating Sunday Liquor 3.2% � 3�� ��.� ����F` �' �� � <br />� <br />�Fee{s): On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ .�" ��f�� ��:� � �.��'-�' � <br />Licensee Name: DOB Social Security # <br />(corparation, partnership, LLC, ar lndividual) <br />Business Trade Name����� r { Business Address ��� �} � r� q����+d.�Citv �t'1 � 5�� � 1� <br />Zip Code�,�� �'� �_�v}���� Business Ph��P ��+� 1� } � �� � � � �_ �ome Phone— � <br />Home Address, � ° ' "� <br />Licensee's Federal Tax ID # <br />_ City <br />Licensee's MN Tax ID # <br />(To Applyca11651-24G•bl�l) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/of�icer: <br />��.��.- � �.��. . , � <br />pant�erlt�Fficer ]�iets�r �f��� i�ilddlr � _ _ �_.... .... �. �,.�.,r ...n,r� <br />�'�+� � .�-�� - _ .� <br />��aCkt '7J�' Q��3C.#' �31i3. � FiTSi M14�P. L3SY� _ nr+� i <br />�1'�.�*f-�� :. <br />Part��erl0f'£`aeer Na�ne (First Middle Last) DOB Social Security# Home Address <br />Into�cating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all of the following: <br />1) Show the exact licensee name (corporation, partnership, LLC, �tc) 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 licensee under the Civil Liquor Liability Law? <br />Worlcers Compensation Insurance is also required by all Licensees: Please complete the following: <br />Worlcers Compensation Insurance Company Name: <br />Policy #. <br />I Certify that this license(s} has been approved in an official meeting by the governingbody of the city or county. <br />City Clerlc or County Auditor Signature Date <br />(tiae) <br />On Sale Intoxicatin liquor licensees must also purchase a$20 Retailer Buyers Card. T o obtain the <br />application for the �uyers Card, please call 651-215-6209, or visit our �vebsite at �+5��.d�s,St��e.��.�s. <br />(Form 9011-ll/05) <br />