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AkMolb Gn. IIM tMorca.M <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 a <br />On Sale Liquor Licens <br />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 sate 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 Count Issuing Liquor License Little Canada License Period From: To: "AS- <br />Circle One: New License License Transfer Suspension Revocation Cancel <br />(former licensee name) <br />License type: (circle all that apply)On Sale lntoxicatinSunday Liquor <br />(Give dates) <br />3.2% On sale 3.2% Off Sale <br />Fee(s): On Sale License fee:$ 4592.00 Sunday License fee: $ 200.00 3.2%On Sale fee: $ 3,2% Off Sale fee: $ <br />Licensee Name:JJ's Hospitality LLC <br />(corporation, partnership, LLC, or Individual) <br />DOB Social Security # <br />Market Place Center, <br />Business Trade Name Fiesta Feb Business Address 2900 Rice Street #380 city Little Canada <br />651-998-9880 Home Phone 651-330-0338 <br />Zip Code 55113 County Ramsey Business Phone <br />Home Address 2367 University Avenue W. City <br />Licensee's Federal Tax ID # 47-2852959 <br />St. Paul Licensee's MN Tax ID # 3856788 <br />(To apply call IRS 800-829-4933) <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 />John Luther SonnackVPIMS <br />Panner/officer Name (First Middle Last) <br />Chen Chen <br />(Partner/Officer Name (First Middle Last) <br />Jorge Arturo Flores <br />Partner/Oficer Name (First Middle Last) <br />790 Millwood Ave. Roseville, MN 55113 <br />0013 Social Security fl Home Address <br />790 Millwood Ave. Roseville, MN 55113 <br />Social Security # Home Address <br />1007 Minnehaha Ave. W., St. Paul, MN 55104 <br />Social Security # Home Address <br />DOH <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 <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:MN Workers' Comp Ins Assn Policy # Application in process <br />1 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 901)•12/09) <br />10 <br />