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H�G-25-09 TUE 6�:2g q� <br />", �n��r� <br />Minncsota Dcpas�tii�etit of Pul�lic: SafC[y <br />Alcol�ol and Garr�bljng Eni'orce�nent Division (AGED) <br />444 Cedar Street, Suite 133, St. Paui, MN SS1Q1-5133 <br />TelePhone f>51-201-7507 Fax 651-297-5259 Ti'Y 651-282-6555 <br />F'. �6 <br />Cerfi�cation o1'an O�i Sa1e Li uor License 3.2% Li unr license or Sunda Li �or License <br />Cities and Counties: You are required by law to complete and sign this for�n to certify the iss+�ance of €he following liguar <br />liceilse t�pes: 1} City issued on sale intoxicating and Sunday Iiquor licenses <br />2) City and CounEy issued 3.2% an and off sale malE iiquor ticenses <br />Name of City ar County lssuing Liquor Liceiise $� �LG License Periad From: 1- �- <br />O�'7 To: l a� -� i-O�j <br />Circle One: Netiv Licei�se License Transfer <br />Suspcnsioii Revocation CanceE <br />(former �icensce narr�e) � {Gtve dales) <br />Liceuse type: (circle al! that apply) <br />,1�( c�.2 `7�[7 <br />� � 3.2% On sale r� � 3.2% pFf Sate <br />Fee(s): pn Sale Lice�se fee:$ �-'�� Sunday License fee: ��3,�o�o- pn Sale fee: $� 3.2°/4 Off Sale fee: � <br />Licensee Na�ne: ��SS r { �(3 DOB Social Security # <br />(corporat:on, partnership, LLC, or Individual) - - - - .— <br />Bi�siness Trade Name s� L-Ckc {,� p� I}usiness AddressZ.(Q � <br />.Si.y�.r��,JG �l.cziy_Rr�s�-�/��.� <br />a:p c�.7�..ri� �/'� c:.u..tr 1'� �G-• T�u�inc�a rriunc � <br />� l- 6 3- 7 r r 3 nome rnone <br />Home AddreSS _ ty Liceiisee's MN Tax ID # <br />Licensee's Federal Tax ID # (To Apply call GS[-296•b181) <br />{TO apply eall lR5 fiQ4-829-4933) � <br />Ifabo�e nan�ed licensee is a cor�oration, partnership, or i,LC, complete the followvi�tg for each nartner/�ffir.er• <br />Partner/Qf:iicer Name (First Middle Last) pQB , � " �"' —� • <br />Suciel 5ecuriry #I Home Address <br />(Par[nerlOfficer Name (First Middie I.asr) <br />Yaru�er�0lYlcer Ivame (FifS[ Midd[e L65[j <br />u�e <br />130B <br />Social Security # <br />Social SeCUrity #� <br />Huiiyc AcJc]tC�s <br />Home Address <br />Tntoxicating liquor licensees n�ust attach a certifcate of Liquoi Liability Insurance to this form. T`he insurance certificate <br />m�rst contain aii of the foIlowing: <br />1) Sh�w the ex�ct liccnsee name (carJsoration, partnership, LLC, ctc) and busincss address as sl�ow,� u�i tlic liccnse. <br />2� i�O�rET Com��ehp�y f}iw i�nenrca r.ori4d aet 6y ek� 1..�..1 .-:ty ..� _._... L'„r.._...a „..iL.,.:�y «e o]:.��,.0 u�a ci�o llceii6c. <br />'�Y � <br />Circle One: (Yes No During Ehe past year has a summons beeii issued to the �icensee �nder ihe Civil Liquot Liabiliiy Law? <br />Workers Comper3satian lr�surance is also required by atl licensees: Please complete tl�e fo]]o�ving: <br />Workers Compensation Tnsurance Company Name: l�iL R/il/= S ►�I,u� Po3icy # <br />I Certify tha[ this license(s) has bee�z approved in an officiak n7ceting by [he goveming body of the city of county. <br />City Clerk or County Audi.tor Signature Date <br />(�i�le) <br />On Safe I�toxicatiitg liquor licensees [n�tsi 2iso purcl�ase a�20 Retailer BUyers Card. To obtain t6e <br />applieation for #he Buyers Card, please caI! 651-201-7504, 03' Vislt Out WebSite at Fv�v�v.dl�S.State.inn.t�5. <br />(Fonn 9Qif-5/06) <br />