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�� �� <br />,� <br />�} <br />.� .�...�... .�,>�..�3<.w� <br />Mi�nesota Depart�nent of public Safety <br />Alcohoi and Gambling Enforcetnent Divisian (AGED) <br />444 Cedar Street, Suite 133, 5t. Pau.l, MN 55101-5133 <br />Te[ephone 65 [-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Attachment A <br />CertiCcation of an On Sale Liauor License, 3.2% Liquor iice�se. or Sunda,y,,,_Lipuor Lice�se <br />Cities and Counties: You are required by law Eo campl�te and sign this fomr to certify tE►e issuance of the following liquor <br />license types: 1) City issued on sale intoxicating and. Sunday liguor ticenses <br />2) Ciry and County issued 32% on and off sate maEt liquor licenses <br />Name of City ar County Issuing Liquor License �f�x�J i j j�? License Period From: To: �Z� t� <br />Circle One: ew Lic� e�se > License Transfer Suspension Revacation Cancel <br />(formar licensee name) (Give dates) <br />License e: circie all that a I ' e t ° �� o <br />ryp ( pp y) ��o;c=i�a��� �d�� 3.2 /a On sal`e iti f�'1 32 /4 Off Sale <br />Fee(s): On Sale I,icense fee:$ Sunday License fee: � 3.2°/a an Sale fee: �'G/ G, �3.2% Off Sale fee: $ <br />Licensee Name:�he NtaCx���SYIOP,�C�. •-CD�d�¢ .�Y�C• DOB '�"" Social Security # � <br />(corporaEion, partnership, LLC, ar [ndividual} <br />Business Trade NameNpc�o�es� ��,� p�r�}1( Business Address (p�� C�ur��l�?o�t�!3�City RO�iIF 1Ip <br />Zip Code.:h51 I 3 County� Business Phone ��r3p � jt��� Hame Phone � <br />Home Address : Licensee's MN Tax ID # ' <br />� � (TD Apply call 6] 1-296-6181 j M_I <br />Lrcensee's Federal Tax iD # <br />(To appky cail IR5 860-829-4933) <br />If above named ticensee is a corporation, partnership, or LLC, complete the �ollowing for each partnerlof�icer: <br />ParCnedOf�icer Name (Pirst Middl Last) DQB Social 5ecuriry #f Home Addrese <br />{PartnerlOfficer Name (First Evliddle Last) <br />� U (�� <br />Partner/OEficer Name {First M.iddle Last) <br />��: <br />DOB <br />Social 5ecurity # <br />Social Securiry # <br />lIome Address <br />Home Address <br />Intoxicatiag liquar licensees rnust attach a certificate of Liquor Liability Insurance to this form. The insarance certificate <br />must contain al� of the following: <br />1) Show the exact ficensee name (corporation, partnership, LLC, ete) and business address as shown on the license. <br />2) Cover campl�tely the license period set hy the lacai ciry or county [icensing authority as shown on the license. <br />Circle One: {Yes � During the pasf year has a summons been issued to the licensee under the Civi] Liquor Liability La�v? <br />WorEcers CampensaEion Insurance is also required by ail licensees: Please complete the following: <br />Workers CompensaEion Insurance Company Name: � �� h 1nS�,z c:� Po[icy # <br />I Certify tE�at this license{s) has been approved in an official meeting by the governing body of the city or county. <br />City Clerk or County Auditor Signature Date <br />(title) <br />On Sale Intoxicating liquor licensees must also purchase a$20 Retai[er Buyers Card. To obiain the <br />application for the Buyers Card, please call 651-201-7504, or visit our website at www.d s.state.mn.us. <br />(Form 90l I-5/06) <br />7 <br />