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MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIVISION <br />ROOM 440 333 SIBLEY ST. <br />ST PAUL, MN 55101 <br />PHONE 612 - 296 -6159 <br />CERTIFICATION OF AN ON SALE AND /OR A SUNDAY LIQUOR LICENSE <br />Ho v.qb INS-. <br />D-P I"I (.f s-f, ..gVl`TE 360 <br />(,I('T 2. rn,�.00A,A.l 3 <br />PS 9011 (I1-e9) <br />IF NAME AND ADDRESS SHOWN ARE <br />NOT CORRECT. MAKE CHANGES IN <br />SPACES BELOW. <br />ISSUING AUTHORITY (Check only one) <br />CITY OF t /DT"- L9A1"A COUNTY OF <br />LICENSEE NAME (INDIVIDUAL, PARTNERSHIP, CORPORATION( <br />kit,/ y,1N1, , I µL, <br />TRADE NAME OR DBA <br />M.Y LE /{'A L 1,,ore6 $4.4rAuMAS <br />BUSINESS ADDRESS <br />29o0 fr,Zj Si,, Svrr( ?VC <br />CITY <br />Lvt1'L(= e,.wldA <br />ZIP <br />; 3/)3 <br />LICENSE TYPE (CHECK ONE OR BOTHI <br />IKON SALE 0/SUNDAY <br />LICENSE PERIOD <br />FROM TO <br />COUNTY <br />AA"ill <br />ON SALE LICENSE NUMBER <br />ON SALE FEE <br />SUNDAY LICENSE NUMBER <br />SUNDAY FEE <br />BUSINESS PHONE <br />Itt/ -.5253 <br />If a Partnership, State the Name and Address of Each Partner 11 a Corporati n, State the Name and Addres of Each OfIicor. <br />PARTNER/OFFICER NAME 1 <br />Ov O- a rrA�Y U/-3 <br />ADDRESS <br />�b3 VNtvE-ni l2' A1/E,/ 41, OAL2.i M^/ s5-1 o3 <br />PARTNER/OFFICER NAME <br />ADDRESS <br />PARTNER /OFFICER NAME <br />ADDRESS <br />The Licensee must have one of the following: <br />CHECK ONE <br />LI A. Liquor Liability Insurance (Dram Shop) — 550,000 per person; 5100,000 more than one person; $10,000 <br />property destruction; S50,000 and $ 100,000 for loss of means of support. ATTACH "CERTIFICATE OF INSUR- <br />ANCE" TO THIS FORM <br />OR <br />B. A Surety bond from a surety company with minimum coverages as specified above in A. <br />OR <br />❑ C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a <br />market value of $10D000 or $100,000 in cash or securities. <br />I CERTIFY THAT THIS LICENSE WAS APPROVED IN AN OFFICIAL MEETING BY THE GOVERNING BODY OF THE CITY <br />OR COUNTY. <br />Given Under My Hand and the Corporate <br />CITY /COUNTY Seal this day of 19 <br />SEAL <br />Clerk of Audilor <br />During the past license year has a summons been issued under the Liquor Civil Liability <br />Law (DRAM SHOP)/ ❑ YES G NO If yes, attach a copy of the summons, <br />COMPLETE THOSE ITEMS THAT APPLY <br />TRANSACTION TYPE e?MEW ❑ REVOKE/CANCEL <br />0 RENEWAL II TRANSFER ❑ SUSPENSION <br />OATES SUSPENSION <br />FROM TO <br />DATE OF REVOCATION/CANCELLATION <br />ADDRESS CHANGE FROM <br />TRANSFER OF OWNERSHIP FROM (NAME AND ADDRESS( <br />Page 4 <br />IMPORTANT NOTICE <br />ALL RETAIL LIQUOR LICENSEES MUST HAVE A CURRENT FEDERAL SPECIAL OCCUPATIONAL STAMP THIS STAMP IS ISSUED BY THE <br />BUREAU OF ALCOHOL FIREARMS AND TOBACCO. FOR INFORMATION CALL 612 - 290 -3496. <br />