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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 55101-5133 <br />Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <br />Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday Liquor License <br />Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor <br />license types: 1) City issued on sale intoxicating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses <br />Name of City or County, Issuing Liquor License d;� Ce64611i- License Period From: To: <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(former licensee name) <br />License type: (circle all that apply) cOn Sale Intoxicating <br />Fee(s): On Sale License fee:$ 7 30 Sunday License fee: $a 60, <br />3,2% On sale <br />3.2% On Sale fee: $ <br />(Give dates) <br />3,2% Off Sale <br />3.2% Off Sale fee: $ <br />Licensee Name:. /-7— de,91-p(-D/341ii d' ,,nf DOB Social Security # <br />(corporation, partnership, LLC, or Individual) 72pp, <br />Business Trade Name <br />Zip Cocle 5"S I I County 4,rr <br />Home Address /t/, St <br />Business Phone <br />Licensee's Federal Tax ID # <br />Business Ad <br />dress y 66 iq e.f6 SO -City ' <br />l /. y&"G% w `7 Home Phone '$"/ &e.1 <br />Sal /t/ City cm er... ted <br />(To apply call LRS 800-829-4933) <br />Clr. M cl Licensee's MN Tax ID # <br />(To Apply call 651.296-6181) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />Partner/Officer Name (First Middle Last) <br />I oy Cr "1') 4.. x°1'2 <br />(Partner/Officer Name (First Middle Last) <br />Horne Address , e <br />1q5 fi cG rt y., <br />Social Security # Home Address <br />Partner/Officer Name (First Middle Last) <br />DOB <br />Social Security # <br />Home Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all of the following: <br />1) Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license, <br />Circle One: (Yes No) During the past year ha's a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br />Workers Compensation Insurance Company Name: Policy # <br />I Certify that this licenses) has been approved In an official meeting by the governing body of the city or county. <br />City Cleric or County Auditor Signature Date <br />(title) <br />On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please call 651-201-7504, or visit our website at s.state.mlx.us. <br />(Form 9011.12/09) <br />