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�''�'�f� Minnesota I]e�artuzenc of Public Safety •���'� <br />�r� ' �' LI UORCONTROLDIVISION �'� 1}•` <br />i � Q ��a*�-�. ,..'� <br />� 444 Cedar St., Suite I04 L, St. Paul, MN 55101-2156 ��'$�,h; ��� <br />���- Fa� (612)297-5259 �'�� " <br />(612)296-6430 TTY (612)282-6555 <br />CERTIFICATION OF AN ON SALE AND!(3R SUNDAY LIQUOR LICENSE <br />�T� �s� �iII ht �ppm���d ar sel�AaCd ���ti1 th� �'D �t�r�Fr Ti� ��rc� �st es ��v�d b}� � Liyuor �'aaa ro1 <br />Workers Compensation Insw-az�r.e Company Policy# <br />LICENSEE'S SALES & USE TEtX W# To apply for sales tax number, call 296-6181 or 1-$dQ-6S7-3777 <br />ISSUTNG AUTHORIfT`Y <br />G'E-C�f � f rt� s r..�•'� COUNTY OF <br />E.icx�n� Tweenc �{'�,E�nral;�,iE, Pn�=��r;t�9p. ?�dt�i�tii�l� ?}€3T3 7'r� T��rrx orDRA <br />r <br />, . {,� <br />�u�siu�ss �dre� �'ity Zip Code <br />��- �•, �, C� 5 7 I �- �� t E i� ��� <br />�i��o� rvpe (�.'��c �o�� ne �#L,� l.r',.�n `l � '�d .# . $ �um,�' <br />-�_`�`� �ol� i !� r�uti � '1'� <br />��n ��It ] �t��n� N��b� �� 4sl�F'o� �uv�au I�;�:ea� Nund�r �u,i�� Foe [�'JSdit��c E'�7C�fLt` <br />lf � nftn��•� . iti71tL' ��1� TJ]I�R�C 71n� ��7C/IF 4t C3�F1 rinee, �{ � ro r�M� �latrt tT� ��:ad �tddrtsx b�e�e �iii�s�. <br />1'o�-��rr�5�ic.cT N�fi�'�rst. m�l� po� aa�l) f)()�3 TNir �� i <br />I � .. � � � { --- <br />r� • L <br />�--r � � ' ^ _.�_.. • <br />F���trJ�f�ir� arn: {�`j�, rr�i�dlc nr,� �,�,f] � Titic � ti J�ddress �� <br />i <br />� <br />ParF.�asr/O�icer Name (First, middle as�� �as�� DOB Titic Address <br />The Licensee mu+�i have one of the fa�la�vz�zg: <br />(ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />C��edc nne <br />�A- LiquorLiabilityInsurance�ra�x Shop) �$50,000 per person; $100,000 a�►�r� than oneperson; $10,000 Properiyi�x��_�a��; <br />$50,000 and $100,000 for loss of ineans of support. <br />� <br />��- A bond of a surety companywith min�rnf� coverage as specified above in A. <br />� <br />n�- A certificate from the State Treasurer that f.he Iicensee has deposited with 1i�� State, Trusrt Funds having a market value of <br />$100,000 in cash or securities. <br />CI Ye3 ��f�' During the past licenseyear has a summons been issued nuder the Liquor Civil LiabilityLaw (Drarri Shop)? <br />If yes, attach a copy of the summons. <br />Check those items that a ir 1 <br />Transaction'I"ype�New Cl �evoke/Canc,el Suspen,�evake/Csncelled <br />LJ Transfer 7 Sus ension From To <br />Transfer of ownership fmm (Name and Address) <br />I ce�tify that this license was approved n an offieiul. meetingby the governing body of k]I�' city or couqty_ <br />City Clerk's Sigz�at�irc Date <br />IMPORTANT NOTICE <br />All retail liquor licenseeg must have a current �'�derat Special Occupational Stamp. This stamp is issued hy the Bureau of <br />Alcohol, Tobacco and Firearms. For information call (612)290-3496 ^� 9011-94 <br />