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Minnesota Departm.,ent of Public Safety <br /> Alcohol and GamblingEnf6rcement Division (AGED) <br /> 444 Cecl~ Street, Suite' !33i St. Paul, MN 55101-5133 <br />Telephone 651~2296-6979 }.Fax 65il-297-5259 TTY 651-282-6555 <br /> <br /> Certitication et'an On Sale ~[quor Lieqnse~3:2/% Liquor license, or Sunday Liquor License <br />Cities and Counties: You are required by !fiw to efm~lete and sign this fo~ to ce~i~ the issuance of the following liquor <br />license types: 1) Ci~ issued on sa~ inmxicat~g and gunday liquor licenses <br /> 2) City and CounW i~sue~;2% on a~d offsale malt liquor licenses <br />NameofCity~r~C~.a~.~s~gLiquorLice~s~O..]~~ License Pefiod From: ~]0~ /~o: ~/~/~ <br />Circle One:~w Lic~~icense TrYster : ~: ~ ': Suspension Revocation Cancel <br /> (fo~e; literate name) .. . (Give da[es) <br />License type: (circle all that apply) On Sale IntoXicating ~ } ~~~:/o On s 3.2% Off Sale <br />Fee(s): On Sale~(~se fee:S. ~oandgy Licensefee: $ 2% Off Sale fee: $ <br />Licensee Name: Social <br /> <br />Business Trade Name &i ~ ¢~ : Bus'ess Address/~ - ~ <br />Zip Code ~D~g Coun~ ~i&~ Business Phon~ ~34 qgD- Yt V~ ~om~ Phone <br /> <br />Licensee's Federal Tax ID ~ ~ ~ ) ~ (To Apply call 651-296-6181) <br /> (T0 apply <br /> <br />if above named licensee is a % <br /> <br /> first <br /> <br />}ration, <br /> <br />(Partner/Officer Name (First Middle Last) <br /> <br />,lete the following for each partner/officer: <br /> <br />Home Address <br /> <br />Social Security # Home Address <br /> <br />Parmer/O£ficcr NaJne (First Middle Last) D°B Social Security # Home Address <br /> <br />Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate <br />must contain all of the t'ollowing: <br />1) Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Covet' completely the license period set by the local city o~ county licensing authority as shown on the license. <br />Circle ()ne: (Yes No) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br /> <br />Workers Compensation Insurance is also required by all. licensees: Please complete the following: <br />Workers Compensation insurance CompanylName: j~.TO ~).L~?/,&.,~-~ ._.~.5_'~ Policy# <br /> <br />[ 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 Car~. To obtain the <br />application for the Buyers Card, pleaseieall 6512215'6209, or visit our website at www.dps.state.mn.us. <br /> <br />(Form 9011-2()[)4) <br /> <br /> <br />