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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />445 Minnesota Street, Suite 222, St. Paul, MN 55101-5133 <br />Alcubal&GDMIingEnloreemenl Telephone 651-201-7500 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 Mounds View <br />License criod From: To: - oZ <br />:Pr,eV',OL4s Lie Lm%..l2-- I . <br />Circle One: ew Lice a License Transfer A uspension Revocation Cancel <br />(former licensee name) <br />(Give dates) <br />License type: (check all that apply) ❑x On Sale Intoxicating ❑x Sunday Liquor ❑ 3.2% On sale ❑ 3.2% Off Sale <br />Fee(s): On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />Licensee Name: American Multi -Cinema, Inc DOB NIA <br />(corporation, partnership, LLC, or Individual) <br />Zip Code 55112 County Ramsey Business Phone 913-213-2000 <br />Social Security # N/A <br />Home Phone <br />Business Trade Name AMC Mounds View 15 Business Address 2430 Co Hwy 10 <br />Licensee's Federal Tax ID # 43-0908577 <br />(To apply call IRS 800-829-4933) <br />City Mounds View <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />Home Address 11500 Ash Street City Leawood Licensee's MN Tax ID # 3594943 <br />Adam Maximillian Aron <br />Partner/Officer Name (First Middle Last) <br />Sean David Goodman <br />5133 Fisher Island Dr. Miami Beach, FL 33109 <br />Home Address <br />7252 W. 139th Terrace Leawood, KS 66224 <br />Partner/Officer Name (First Middle Last) Home Address <br />Kevin Michael Connor 833 Westover Road Kansas City, MO 64113 <br />Partner/Off ccr Name (First Middle Last) DOB Social Security # Horne Address <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must <br />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 />❑ Yes ❑x 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: ACE American Insurance Compay policy # XSLG71572869 <br />I Certify that this license(s) has been approved in an official meeting by the governing body of the city or county. <br />CityG-larkorfr Signature Date' <br />ad-,� , {tit <br />On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the application <br />for the Buyers Card, please call 651-201-7504, or visit our website at www.dps.state.mn.us. <br />