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~ Ce=rS,.. S,,i:e ~, Se. P:u~. M~ ~StO,-s~:Y". <br /> <br /> (651)296-6979 ~ (651)282.6555 .... :.' -" .... <br /> <br />CERTIFICATION OF ~N' ON S~E ~ND/OR SUNDAY LIQUOR Lt. CENSE <br /> <br />No license will be app.r, oved or. released until the :i20..Retailer. LO Card-fee is rec,qv,d <br /> <br />Workers Compensation Insurance Company <br />LICENSEE'S SALES &USETAX[D# <br /> <br /> Policy # <br />To appty for Sales ca.~. number, call (651 )296-6 l 8 or 1-800-657-3777 <br /> <br />I <br />I <br />I <br />I <br />I <br /> I <br /> I <br /> <br />CITY OF <br />License= Name (Corporation, Pa,~nership,_~.r t C, Individual) <br /> <br />B~ines~ Addras~ <br /> <br />On Sale b~cense Number j Fo: Pard to City <br /> I <br /> <br />,- COUNTY OF 0 ~/. ~'~ <br /> DOB Social Security # ] Trade Name or DBA <br /> I <br /> , City '~O~%. E~ F - Zip. Code~O~ .... <br /> -[ bit,se Period County <br /> <br />Sunday b~cense Number Fee Prod to City ] Busmes-~ Phone <br /> <br />Ii a corporation, parmersnip, LLk., state the aarne oate oi DIl~ll, SOCllli security /~and aOclress ol each pa~ner Or oilicer. <br /> <br />Parmer;'Otfic:r Name (First, mmol¢ ann tat)l_DoB <br />P2~r/dfficcr Name (First, middle ~d t~0 DOB <br />Pa~er,'Offi~:r Name (First, middle and Itt) DOB <br /> <br />Thc Licensee must have one at'the Following: <br /> <br />CnC. k one <br />© <br /> <br /> C. <br /> <br />Yes <br /> <br />Address <br /> <br />SS# Title Address <br />SS# ~Titie Address <br /> <br /> (ATTACH CERTIFICATE OF [NSUP,.&NCE TO THIS FORM.) <br /> <br />Liquor Liabili:y insurance (Dram Shop) - ~;50.000 per p~rson; $ t00,000 more than one person; $10,000 Proper~y Oesmaction; <br />.c50.000 and 2 [00,000 For loss of means o('suppom <br /> <br />A bond ora surety company with minimum coverage <br /> <br />A certificate from the State Treasurer that the licensee has deposited with the State, Trust Fun~ having a market value o¢ ] 100,000 <br /> <br />No During the past licmse year has a summons be:n issued under the Liquor Civil Liability Law (Dram Shop)? <br /> It' yes, neath a ca=y of the summons. <br /> <br />C.q¢ck those tlems that aDoiv L~lrCle one <br />Transacnon T~e ~ P..evoke/Cancei Suspend/Revok~JCanceiled <br /> Tr~sfer Susp~sion From . To <br /> <br />Transfer of ovrnershlp from (Name and Address) . .,,,., <br /> <br />cem~ ihat th~s lic~se was approved tn an official meeting by the governing body or,he c~ty or county. <br />City Clerk's Signature <br /> <br />Date <br /> <br />All r~taii IMPORTA. NT NOTICE <br /> liquor licensees must have a current Federal Special Occupational Stamp] This stamp is issued by the Bureau Alcohol, <br />Tobacco and glrearms. For information call (651)2.90-3496 (PS 9011-98) <br /> <br />-66- <br /> <br /> <br />