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Minnesota Department or' Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT <br /> 4~4CedarSt.,Suite133, St. Paut,Fax (65,)297-5259MN55101'5133 <br /> (651)296-6979 ~ (651 )282-6555 <br /> <br />CERTIFICATION OF A_N ON S.4&,E AND/OR SUNDAY LIQUOR LICENSE <br /> <br />,:. No' license will be app..rove, d' or ~teased until the $20i~Re~ai!e~ ID. Ca. rd, fee is~ ~ece!iV~d ~: <br /> <br />Workers Compensation Insurance Company Policy # <br />LICENSEE'S SALES & USE TAX ID # To apply for sales tax number, call (65l)296-6[8I or t-800-657~3777 <br /> <br /> ~ rssumc ^UTHOm,¥ <br />CITY O~ ~'~~ ......... e-~ . .. COU~,V O~ ~ ~m- .. <br /> Licensee Name (Co~oration~a~ership, LLC, [nd/vidua[) DOB Social Security ~ Trade Name or DBA. <br /> Business. A~ress /' . City <br /> <br /> Licens~(Ch~ one or ~h~ Cicense Period ~ County <br /> On Sale License Number ~o City I Sunda;License Number ]' Fee Paid to City Business Ph~ '' <br /> / <br /> It'd k~rporatioa, partnersh[¢ LLC, state ghe dame date o[ bi~h; social securi~ ~and addres~ ot' each pa~ner or oi'licer. <br /> <br />er/Ot'ficerNa~e (First, middle and l~t) DO8 ~S~ .... ~ ~i}le Address ' <br /> <br />yer/OfficerMame(F2sr, middle and l~t) DOB SSg Title Address <br /> <br /> Pa~e~fficer Name (First, middle and l~t) DO~~ SS~ Title Address <br /> <br /> (ATTACH CERTIFICATE OF I~SU~BCE TO THIS FO~M.) <br />ch~ <br />~ Liquor Liability Insurance (Dram Shop) - $50,000 per person; $100~000 more than one person; SI0,000 Property Des~ucfion; <br />$ 50,000 and $ 100,000 6or loss o ~ means o f suppo~. <br />B. A bond ora surety company with minimum coverage ~ specified above in A. <br />C. A ~enificate from the State Tre~urer that the licensee has deposited with the State, Trust Funds having a market value o6 ~ [00,000 <br />Yes ~Dudng the p~t license year has a su~ons been issued under the Liquor Civil Liabili~ Law (Dram Shop)? <br />If yes, a~ach a copy oFche sumons. <br />Uhefi~ rhS~ ~tems that ao~L~ ..... C~rcle on~ ..... <br />Transaction T~~ Revoke/Cancel Suspen~evoke/Cancelled <br />Transfer Susp~sion From , To <br />[ cem~ that this license was approved in an officia~ meeting by the governing body o~the city or county. <br />Cky Clerk's S[~ature Dam <br />IMPO RT~T ~OTIGE <br />All retail liquor licensees musr ~ave a carreat Federal Special Occupational Stamp. This stamp is issued By tge Bureau Alcohol, <br />Tobacco and Firearms. For information call (651)29~-3496 (PS 90[ 1-98) <br /> <br /> I <br /> I <br /> I <br /> I <br /> I <br />I <br />i <br />I <br />I <br />[ <br />I <br /> <br />I <br /> <br />-174- <br /> <br /> <br />