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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 L.;ffie CGNAck License Period From: To: <br />Circle One: License Transfer Suspension Revocation Cancel <br />(former licensee name) (Give dates) <br />License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale <2% Off Sale <br />Fee(s): On Sale License fee:$ Sunday License fee: $ <br />Licensee Name: �, a�.+� 1 e q, y O o a <br />(corportt'ion, partnership, LLC, 67/Individual) <br />DOB 1 <br />32% On Sale fee: $ 3.2% Off Sale fee: $ <br />cial Security #- <br />Business Trade Name &ateQU 5 '4e LtP,.,.0a2. f.YBusinessAddress I;ett/VeitS La ity CAithic , <br />Zip Code55! /3 CountyQAMSey Business Phone 4s/'tlfrq-5797- Home PhoneCe // - 303 -S'yt -8-897 <br />Home Address 2 /6 12154 AUe Ale City ('3 /taint& <br />censee's Federal Tax ID # ?o - O7143? .1-si <br />(To apply call IRS 800- 829 -4933) <br />Licensee's MN Tax ID # (2$65 1)'2- <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 />d /lm t2ts'f AYE NE <br />er Officer e (First Mi least <br />Partner/Officer ( Last) DOB Social Security ii Home Address <br />(Farmer /Officer Name (First Middle Last) DOB <br />ght "Vel d4 A/ f g341 <br />Social Security # Horne Address <br />Partner /Officer Name (First Middle Last) DOB Social Security # 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 />I) 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 <br />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.mn.us. <br />(Form 9011-12/09) <br />2 <br />