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t <br /> AlcahG{S:�ant6lsnan Erfar�serent <br /> Minnesota Department of Public Safety <br /> Alcohol and Gambling Enforcement Division (AGED) <br /> 444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 <br /> Telephone 651-296-6979 Fax 651-297-5259 TTY 651-282-6555 <br /> Certification of an On Sale Liquor License, .2% Liquor license or Sunday Li uor 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 o Cit or County Issuing Liquor License ! /r15 License Period From: To: <br /> G>�3a� tC'S <br /> Circle One: icense Transfe L--x<<, vn K Suspension Revocation Cancel <br /> (former licensee name) (Give dates) <br /> License type: (circle all that apply) On Sale Intoxicating 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:k� � � LDOB-- � 4 <br /> (corporation,partnership,LLC,or Individual) <br /> 10 _ ,� . <br /> Business Trade Name\,� y��Qr2�;=� I �;;1; �' I Addresst_nn'�1� W' ��d"'�r�1 �ity <br /> Zip Code rLe 4-1--�County CTo 'ii1isiness Phone 7;A—G-P % 11,4`l i Home Phone IS 1 <br /> ;Address °3N��� c.i .(0 LAn � �City ���r10. i��l �6-1��Licensee's MN Tax ID#��r���� 9 <br /> (To Apply call 651-296-6181) <br /> Licensee's Federal Tax ID# <br /> (To apply call 651-290-3905) <br /> If above named licensee is a corporation, partnership,or LLC,complete the following for each partner/officer: rl hoc <br /> 3--;k\ zj C r' <br /> :2-4 1(2!-3 <br /> Partner/Officer Name (First Middle Last) DOB Social Security# Home Address <br /> (Partner/Officer Name (First Middle Last) DOB Social Security# Home Address <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 <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 io 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: Policy# <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 <br /> �..� application for the Buyers Card,please call 651-215-6209, or visit our websrte at www.dps.state.mn.us. <br /> (Form 9011-2004) <br />