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,�Y---. <br />�� � <br />kx.:tJ L ;.r:: :' :. � _ ..r. <br />MinnesotaDepartment of Public Safety <br />Alcohol and Gambling EnforcementDivision (AGED) <br />444 Cedar Street, Suite 133, St. Paul, �VIN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 'i"�'X 65I-282-6555 <br />Certification of an On Sale Liq�or License, 3.2% Liquor license. or Sunday Liqtuor 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 />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 i.��7s� '�� License Period From: 4� �� j� To: ���/I�iG <br />t� <br />Circle One: �few �.eca���� License Transfer Suspension Revocation Cancel <br />(fortrRer licensee name) (Cive dates) <br />License type: (circle all that apply) �?n 5nlc Intoxicatin �un�l�}� [,iqup� � 3.2% On sale <br />�'ae(s): On Sale License fee:$_�1� Sunday License fee: �_� ��� 3.2% On Sale fee: $ <br />Licensee Name:,��, _ ��iy, '� f �� ,��� �1 ; D(}$_ �eGunty �� <br />(Corporation, ��ershi�, LLC, or In�i idual) .. . '- ' <br />Y~ � <br />� �- <br />F5,«i rir-�.� '�ra�l� t�'�i�i� �'� r�wn � �����TI'�i'��'�,�. ]3us i:���s .�ddCess l� ' �� <br />� . .. .. �� <br />7_�� �'i�d�� L� {'��Sn�}'�`5�� ]�us ia�ss P}rr,i7e_��:s� G.5' Olal� i� _, Harn� Phcua _ <br />_ . � <br />Home Add <br />Licensee's Federal Tax ID #— <br />_ � .— <br />� <br />(To app1Y call IRS R'M.�4,.7�-�P�3ti <br />3.2% Off Sale <br />3.2% Off Sale fee: $_ _ <br />� <br />_ ���'. �����.� - -- <br />_. yice�See's � Tax ID � <br />(To Apply c��� 651-296.6181) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each parttier/afficer: <br />Yartner/(?ffieer� �iit fPI�F ��� �r�5 DOB Social Security# Home Adc�rass <br />.i_ � �� - - <br />{E`artnerr�ffiker Non•�e +,T�i�! �iu�le 1 a�j 1��1z £^•��' 4•r.._:`. : ��CI!L' :�CSR'7'G <br />.. �� <br />Fnrincr.7af6a�Narrte (FirstMiddlel�ti DOB . Social5ee�u�j�y# � . i HomeAddress <br />Intoxicating liquor lrce�sees must attach a certi�cate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all A�t�e following: <br />1) Show the 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 �T��'n'�; During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Worlcers Compensation Insuranceis also required by all licensees: Please completethe following: <br />Workers Compensation Insurance Company Nazne._, _� Policy #\ <br />I Certify that this license{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 />(titie) <br />On Sale Intoxicatin�g 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 w�`bs�te at �www.dps.s��t�.tr�n.us. <br />�h'�rnr S�4E i=3r1]6� <br />�� <br />