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[ �d <br />Afcul�vl & EmiEG Iiny £ulwc�v�=•ns <br />Minnesota Department of l�ublic Safety <br />Alcohot and Gambiing �nforce�nent Divisior� (AGED) <br />444 Cedar Street, Suite ].i3, St,. Paul, MN 55101-51.33 <br />Telephone 6�1-20I-7507 Pax 651-297-SZ59 TT Y b51-282-655� <br />Attachment A <br />Certific.atian of an On Sale LiAUO,r License, 3 2,% L,ipuor licen,se, or Sund,av LiQ�or License <br />Cities and Counties: You are r�quired by la�� to cor3-�plete and. sign this forn3 to ce�-tify the issuance of the fo]]awing liquor <br />license types: t} City issued on sale iniox.icating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt �ic�uor licenses <br />Name of City or County ]ssuing �.iquor License__ �u �t V t� (,. L� License Period From'���' ► 20,04 To: ��. (,� ,Pp(� <br />_..�_-_ � <br />Circle One: etir Licens Li.cense "l�ransfer 5uspension Revocation Cancel <br />(forn3er licensee aamc) <br />License type: (circle all t�iai apply) On Sale ]ntoxicating Sunday Liqtzor �.2% ��l sale <br />Fee(s}: On Sa[e E.icense fee:$ Sunday License fee: $ 3,2% �n Saie fee: � <br />ive dates) <br />32°fo Off �ale <br />3.2✓o Offi Sale fee: �• � <br />I,icensee Nacne:__„ _���_��� _ _ DOB� _. al Security �— <br />(corporatron, pannership, LLC, or Individuai} <br />. ` <br />f3usiness Trade I�lame f�f � ja L* Business Address L�� i�� r City nj�, V ��, . <br />ZEp Code ��, r t 3 County�� Business Phone_ �sl ��;/_��i.! Z Nome Phone <br />Home Addres: -� T�icer�see's MN Tax iD #� <br />Licensee's T'ederal `�'ax YD # � ' � C�oApplycall65]-�9b-618]) <br />(To apply call IR$ 800-829-q933� } � <br />]f above narned licensee is a corporation, partnership; or LLC, compfe#e the following %r each partn.ei•/officer: <br />Partner/Officer Nan7e {First Middle Last} llQB Social Security # HOIriO HOUi'e�a , <br />(Partner/Offcer Name (Pi�st Middlc Last) <br />Partner/0ffcerName (l�it-st Middle l,ast) <br />DOB <br />D0�3 <br />Socia] Security # <br />Sociaf Securitv # <br />F[otne Address <br />Home flddreSS <br />Intoxicating ]iquoi• licensees must attacl� a certificate of Liquor LiabiJity Cnsurance to this form. The insurance certificate <br />must contain a]] of the folloti�ing: � <br />]} Show the exact licensee name (cor��oration, partnership, LL,C, etc) and business address as shawn on ihe license. <br />2) Cover completely the [icense period set by the local ciiy or county licensing authority as shown on the license. <br />Circle One: (Yes No} During the �ast year has a summons been issued to the licensee ut�der the Civil Liquot� Lia�ility [,a��+�? <br />Workers Compensation lnsura�ce is also rec�uired 6y a[i licensees: Piease complete the following: <br />VVorkers Compensatian ]nsurance Company Name: � � � � � rpU �'olicy #t �d�� �l Z�v <br />I Certifjf that this license{s) has been approved in an official meetin�, by the_govei•ning body of the ci.ry or co�nty.. ,,, <br />City Clerk or Counry Auditor 5ignature Date <br />� (tille) � � <br />On Sa�e Intaxicating liquor licensees must also purchase a�20 Retailer Buye�-s Card. To obtai�� tl�e <br />application %r the Buyers Card, please call 651-201-7504, or visit our rvebsite at rvw�i�.��s.state.n�,z.��s. <br />(1=onn 9011-5/OG) <br />