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���� <br />Attachment A <br />Minnesota Department of Public Safety <br />Alcoi�o] and Gambltng EnFarcernent �ivision (AGED) <br />444 Cedar S�reet, Suite 133, St. Paui, MN 55101-5133 <br />Telephone 6S I-?O 1-7507 Fax 65 l-297-5259 TTY 651-282-655� <br />Certi�cation of an On Sale_Liquor Lic„ense 3.2% Lipuar Iicense, or S�nd,ay LiQUOr L,icense <br />Cities ancf Counties: You are req�rired by law to complete and sign this %rm to certify the issuance of the following liquoa� <br />license types: ]) City issued on sale inkoxicating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />i <br />Na�ne of City or Caunty Issuing Liquor License � V f�. �. License Period From:_ �ti 1 2oeq To: �C _ (� ,Zp(D <br />_�=..—_x <br />Circle One: ew Licens �.icense 7'i•ansfe�• Suspension Re�tocation Cancel <br />(fo:-mer licensee name) <br />License type: (circle a]] that apply) On Sate Intoxicating 5unday Liquor 3.2% On sale <br />Fee{s): On Sale License fee:S Sunday License fee: $_ 3.2% On Sale fec: $ <br />Licer�seeName: ►�f �D ��;,uG �OB�- ,- ---. aLSecurity�_ <br />(corporation; partnership, LLC, or Individual) <br />ive dates) <br />32% Off 9ale <br />3.�% Off Sale fee: �= C.� <br />Bt3siness Trade Name_ iV� �^/C Business Address Z�r � p�.l �� 3� City qJ�, V ���, � <br />Zip Code "�� rt3 County�,��.,r4 $usiness Phone__6S'/ ��y_�S�L Ho�ne Phone <br />-_�,�_�rr <br />Home Addres: -- Licensee's M� Tax lp � <br />' � (7o Apply cal I(i51-296-b I 8]) <br />Licensee's Federal Tax ID # � <br />(To apply call IRS 500-829-q933) <br />If abo� e named licensee is a corporatioi�, pa�inership, or LLC, compteta the following far eacF7 partner/officer: <br />� <br />Partner/OfficerNa�z�e (I�irsc Middle I,ast} DOB Social Securi[y # Home.vnarc�, „ <br />(Partc�cr/QFficer T�Iame (First Middle Last) <br />Partner/Officer Name (Pirst Middle Last} <br />DOB � <br />I� � t <br />Soci�3l Securily # <br />Social 5ecuritv # <br />Ilame Address <br />�Iome Address <br />lntoxicating liRuot� licensees must attach a certi�cate of Liq.uor Liability Insurance to this for�n. T��e insurance certi�cate <br />must contain all of the tollowing: � <br />]} 5how the exact licensee �ame (corporation, partnership, LLC, etc} and l�usiness addre5s as shown on ti�e license. <br />2) Cover co�nplztely the Jicense period set by the ]acal city or county licensing authari:ty as shown on the license, <br />Circle One: (Yes No) During the past year has a suinmons been issued to tl�e licensee ui7der the Ci�il Liqiior Lial�ility La.v? <br />Workers CompeFlsation ]nsurance is also required 6y al� licensees: F'lease cocr�plete t'he follow�ing: <br />Vb'arkers Compensation Insurance Company Name: IV �� 1 y-� rpU po]I�y �t ��%�� ��2�� <br />[ Certify that this license(s) has been approved in an official �neelin� by the.governing body of the city or county. ,�, <br />City Cler4c ar County Auditor Signature Date <br />1 (tiue) � — � <br />4�i Sale Tntoxicatii�g iiquor licensees must aIso purcl�ase a$2a Ret�iler Bu}�ers Carc�. Ta abtain t��e <br />a�pTic�tion for the B�yers C1rd, piease call GSI-201-7504, or visit a�r rvebsite a� �r��ir�v.�f��s.state.mn.us. <br />(Fo,if� 94t 1-5/06) <br />