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� <br />. , { <br />4•• J <br />�. . <br />���i•a 4�'. . , � • ,r <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 />Telephone651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certi�cation of an On Sale Liauor Lieense. 3.2% Liauor license. or Sundav Liauor 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 />] i <br />Name of City or County Issuing Liquor Li�en�e ��, li 4�� �, License Period From: k! �� To: <br />�~-- <br />Circle One: ���' LEa�ns,e� License Transfer Suspension Revocation Cancel <br />(former licensee name) (Give dates) <br />�-� -- <br />License type: (circle all that apply) On Sale I��ax�catin �ur�cl�}+ LGguar� 3.2% On sale 3.2% Off Sale <br />� � � <br />Fee{s): On Sale License fee:$�_ Sunday License fee: $�,� �'—° 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />Licensee NfunG; ��.�� � �(�L 170B_ _ Social Security � <br />(corporarion, p Fn�rship, LLC, or I�di�idaal) <br />BusinessTrade Nari�� � � ���j,�f ���µ�'� Business Address�� � i�� �� City_� �� <br />�i �a Cad�� � l3 �'o�nt}��,�� B�i� F�h4[u� ��l ��• Olalr� U� �Home Phone. <br />Home Address. �it� �-��t.[t..QiL 4�G ���a t�'�ra+ Licensee's MN Tax ID 3 <br />(To Ap�4ycall651-296-6181) <br />Licensee's Federal Tax ID # <br />� - -. � r 3) <br />If above named licensee is a corporation, partnershfp, or LLC, complete the following for each partnerlofficer: <br />Q�m��,',��� �� �'irs� Middle Last) n�R Social Securiry# Home ri�i�rrsx <br />�r:.r.._�mr��...�,..,,� �,�r�',�,�ykK,+.� DOB SocialSecurity# <br />Home Address <br />Aartnerl(�f�icerName fFiXSiMiddleLast) DOB _ SocialSecuri� �s <br />Intoxicating iaquor �tcen5ees musr at�ac�t a certi�cate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all of the following: <br />i) 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 bj 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 />Workers Compensation Insurance Company Name: <br />Policy <br />I Certify that this lieense{s) has been approved in an of�cial meeting by the governing body of the city or county. <br />City Clerlc or County Auditor Signature Date <br />(title) <br />O n Sale ini��i�tia liquor licensees must also purchase a$20 Retaller Buyers Card. T o obtain the <br />ge���kica ii,�� ffEr tl�� �uyers Card, please ca11651-215-6209, or visit our website at www.dps.stak�.mn.us. <br />(Form 9011-5/06) <br />