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Maafial&Oar, ITnp dominant <br />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 Licenses, i // (,0A(// J License Period From: To: 6-2---/e, <br />Circle One: <br />License Transfer Suspension Revocation Cancel <br />(Give dates) <br />License type: (circle all that apply) <br />(former licensee name) <br />On Sale Intoxicating) <br />3.2% On sale 3,2% Off Sale <br />Fee(s): On Sale License fee:$ Su day License fee: $ 3.2% On Sale fee: $ ' 3.2% O'ff Sale fee: $ <br />e.S1-6c.1R ,Ot. L..L(`,. <br />Licensee Naine:E/ .,.5e,-kihR(*) /91eN, /IA 4) D Social Security # <br />(corporation, partnership, LLC, or Individual) <br />Business Trade Name L. 561i 1j/ e ff) , le.,,c 'm,t} Business Address t;:;2�62 l it?,e. <br />Zip Codes/I`7 County <br />Home Address <br /><'. Business Phone (, /- 4/9 q7/5 Home Phon <br />City Licensee's MN Tax ID #170 <br />Lift/c • , <br />City /4r 4' <br />Licensee's Federal Tax ID # 4/7 -- 445..29,5 -co <br />(To apply call IRS 800-829.4933) <br />(To Apply call 651-296.618I ) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each .ar <br />iJD 4) <br />Partner/Officer Name (First Middle Last) DOB ocial Security # Home Address <br />• <br />(Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />Partner/OfficerName (First Middle Last) DOB Social Security # Home Address <br />Intoxicating liquor licensees trust 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 has 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 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 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please call 651-201-7504, or visit our website at www.dps.state.Inn.us, <br />(Form 9011-12/09) <br />