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 ~'.'"'~." ,~ '*,4'.'~', <br /> Minnesota Department of Public Safety :;'kr...:~:~ ~:,,-..~'~ <br /> ALCOHOL AND GAMBLING ENFORCEMENT D~ISION <br /> 4~4 Cedar SL, Suite 133, S~. P~ul, MN 55 i0I-5 <br /> (65 I)296-6979 ~ (65 I)282-6555 <br /> <br /> CERTIFICATIO~ OF ~ O~ S~E ~D/OR SUNDAY LIQUOR LICENSE <br /> ~0' license will be apPr0~ed or:rdeased uatfl the $20:..~a!le <br /> <br />Workers Compensation Insurance Company Policy <br />LICENSEE'S SALES ~ USE TAX [D ~ To apply for sales tax number, call (65 l)296-6 l 81 or 1-800-657-3727 <br /> <br /> [KxF) ~O,f,, ~ ~__.,....\ ~ISSUING O~'~AUTHORITY~ _~ ~ ~-- <br />CITY <br /> OE <br />Licensee Name (co~mfio~ Pa=¢rship, LLC, Individual) DOB Social Secu~ty ff ~rade ~am¢ or DBA <br /> <br />~ ( Sun~) From To <br /> <br />Ifa eorporanon, parme~s~ip, bLC, state ~e name dat~ o[ ~, socinl securi~ ~an~ =ddress or' eac~ pn~ner or oHicer. <br /> <br />.ormcr/OfficerName (First, middle and last) ¢¢fil/; SS; . ' '' Address <br /> <br />P'a~er/Of~cer Name (Fir~t~ midflle and t~t){ DOB SS~ Title kddresk' " <br /> <br />Pa~er/~eer Name (First, middle and l~t DOB' SS~ Title Address <br /> <br />The Licena.eJ: must hav4~ne oCtb. e following: <br /> (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />Liquor Liability Insurance (Dram Shop) -$50,000 per person; $100,.000 more than one person; $10,000 Property Destruction; <br />$50,000 and $100,000 for loss of' means of, support. <br /> <br /> B. A bond of a surety company with minimum coverage as specified above in A. <br /> <br /> C. A certificate fi.om the State Treasurer that the licensee has deposited with the State, Trust Funds having a market value of S 100,000 <br /> <br /> .... in r'q~h or' ~,~r'Hmti~,q <br /> <br /> Yes ~uring the past license year has a summons been issued under the Liquor Civil Liability Law (Dram Shop)? <br /> <br /> IEyes, at'tach a copy of the summons. <br /> Check: rlnose ttems that apply <br />I Transaction T~ Revoke/Cancel <br /> Transfer Suspension <br /> <br />C~?cl& one <br />Suspend/Revoke/Cancelled <br />From . To <br /> <br />Transfer of' ownership From (Name and Address) ~/,.~/ <br /> <br />I certify that this license was approved in an of,ficial meeting by the governing body of the city or county. <br />City Clerk's Signature Date <br /> <br /> IMPORTANT NOTICE <br />All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau Alcohol, <br />Tobao'o and Firearms. For information call (651)290-3496 (PS 901 IO8) <br /> <br />-228- <br /> <br /> <br />