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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 TrY 651-282-6555 <br /> <br /> Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday Liquor 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: I) City issued on sale intoxicating and Sunday liquor licenses <br /> 2) City and County issued 3.2% on and offsale malt liquor licenses <br /> <br />Name of City or County Issuing Liquor License ~,..,.-~,i~ License Period From: To: <br />Cimle One: ~-ew Licen~g'2 License Transfer Suspension Revocation Cancel <br /> (former !icensee name) (Give dates) <br /> <br />License type: (circle all that apply) <l~)n Sale IntoxicaUng j ~ 3.2% On sale 3.2% Off Sale <br />Fee(s): On Sale License fee:$ ~:ff:~. Sunday License fee: $ ~Xg. 3.2% On Sale fee: $ __3.2% Off Sale fee: $ <br />Licensee Name: ~xl e_\~,~ ~__~"~-Cr,',~,,c~ DOB Social Security # 14 '1 ~ - qq- S %S 'z~ <br /> (corporation, partnership, LLO, or Individual) <br />Business Trade Name ~0.\~ ~,',.-~-,"~, t¢~ Business Address ~4~/'~c/~LO~'3f ~-i0 %LO City FL a..,v.,,se..~ <br /> <br />Zip Code County P~,.a ~t.,~- <br />Home Addresst,~-~ '/ Ilt~-'?'~tl,,a,:.. r~ <br />Licensee's Federal Tax ID <br /> <br />Business Phone <br /> <br />Licensee's MN Tax ID ~ <br /> (To Appl~ <br /> <br />Ifabove named <br /> <br />~, or LLC, complete the following for each partner/officer: <br /> <br />Partner/Officer Name (First Middle Last) DOB Social Security # <br />(Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />partner/Officer Name (First Middle La.st) DOB 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 following: <br />1) Show the ex. act licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. <br /> <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license. <br /> (Yes ~) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Circle <br /> One: <br /> <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br /> <br />Workers Compensation Insurance Company Name: Policy #. <br /> <br />I Certify that this license(s) has been approved ;n an official meeting by tJ~e governing body of the city or county. <br />City Clerk or County Auditor Signature__ '~ _ Date <br /> (title) <br /> <br />On Sale Intoxicatin,~ liquor licensees must also purchase a $20'Retailer Buyers Card. To obtain the <br />application for the nuyers Card, please call 651-215-6209, or visit our website at www.dps.state.mn.us. <br /> <br />(Form9011-11/05) <br /> <br />-102- <br /> <br /> <br />