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Minnesota Department of Public Safety ' <br />C Alcohol and Gambling Enforcement Division (AGED) <br />°• x�. 445 Minnesota Street, Suite 222, St. Paul, MN 55101-5133 <br />Alcohol'& GamblingEmmeement 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 4" p License Period From: To: <br />Circle One: GLicense License Transfer Suspension Revocation Cancel <br />(former licensee name) (Give dates) <br />License type: (check all that apply) ❑On Sale Intoxicating ❑ Sunday Liquor ❑ 3.2% On sale D<3.2% Off Sale <br />Fee(s): On Sale License fee:$ Sunday License fee: $ 3.2% On Sale fee: $ 3.2% Off Sale fee: $ IOa <br />Licensee Name: knovJ 40l1 Y&ACEf5 T..u.. DOB Social Security # <br />(corporation, partnership, LLC, or Individual) <br />Zip Code County Business Phone Home Phone <br />Business Trade Name f <br />95ha& ( FO-dS Business Address Iy7%S J;c4or qmo o l3w. City <br />v <br />Licensee's Federal Tax ID # <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 City Licensee's MN Tax ID #c(56 I uis <br />U.ulr 5 1S, q u; s f <br />Partner/Officer Na ie OlUst Middle Last) DOg Social Security;; <br />Partner/Officer Name (First Middle Last) — 0{ Social Security # <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 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 MNo 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: jeLu.ra Tn5uAroAU^- Policy # WL3�-t I T <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 application <br />for the Buyers Card, please call 651-201-7504, or visit our website at www.dps.state.mn.us. <br />