Laserfiche WebLink
Minnesota Department of Public Safety <br />ga�j�(NDW Alcohol and Gambling Enforcement Division (AGED) <br />445 Minnesota Street, Suite 222, St. Paul, MN 55101-5133 <br />Alcahal&GamhiingEnlorcament 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 />Natne of City or County Issuing Liquor LicenseP&M h �f V,'nks License Period From:* L';10;I zTo: 0 <br />Circle One =LicenseLicense Transfer Suspension Revocation Cancel <br />{fontter licensee name} Suspension <br />dates} <br />License type: (check all that apply) 5f On Sale Intoxicating Dq_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% OffSale fee: $ <br />Licensee Nam + <br />e: [ -P "A h 0.5 4Z , G G C `DOB Social Security A 4llj <br />(corporation, partnership LLC. or Individual) <br />Zip CoderJ' 5/; 2, County 144 h t'►, business PhoneA/0- .t t apkoi—t f-Iome Phone ;70 a% <br />1- <br />Business Trade Name pbf #ej, Ile ttrc" Business AddressaS J5;-C/y yf , y % City ,,.,,/r �.. <br />Licensee's Federal Tax ID # g$ 3� J .'3 7 T d <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />Home Address <br />Partncrlpliicer Name (First M iddle- Last) <br />`MCI I Car! e7, <br />j <br />Partner/Off iccr Name (First <br />pMiddle Last) <br />�' I 5,0 a <br />-) ! I . RI V,4,,-e1 <br />City <br />Licensee's MN Tax ID # pL <br />woo 1 h a^ 1� <br />Horne ddress <br />=61) 77 7-440a4/plhaf 6-0)0-Yy <br />aa �yf-tine Addres <br />■ <br />Partner/0fficcrName (First M i d d I c Last) DOB Social Securijy W Hnm Ad <br />�-47 r <br />Intoxicating liquor licensees lntist attach a certiIiicate 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 N1 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 <br />Heartman Insurance <br />Policy # <br />QWC1257608 0 <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 <br />(title) <br />Date <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.mnl.us. <br />