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.. <br />si <br />nseai�«ta:.aw�as�+er�+ <br />Minnesota Departmel <br />Alcohol and Gambling Enfor <br />444 Cedar Street, Suite 133, <br />Telephone 651-201-7507 Fax 651 <br />t of Public Safety <br />.ement Division (AGED) <br />It. Paul, MN 55101-5133 <br />297-5259 TTY 651-282-6555 <br />Cities and Counties: You are required by law to complete and s <br />license types: 1) City issued on sale intoxicating and S <br />2) City and County issued 3.21/6 on and i <br />Name o Ci County Issuing Liquor License <br />Circle One: ew License License Transfer (former license <br />License type: (circle all that app 1y)ntoxrcatin� <br />Fee(s): On Sale License fee:$ Sund y License fee: $ <br />_ ,.fk-.ny 3 D <br />Licensee Name• C� �� s �`' <br />(corporation, partnership, LLC, or Individual) <br />Business Trade NamTZ v <br />Zip Code_ County.4.n.0 Business Phone <br />Home AddresCity Pte: <br />Licensee's Federal Tax ID # �C' f z/ 3`;4 00 <br />(To apply call IRS 800-829-4933) <br />If above named licensee is a corporation, partnership, or LLC, c <br />Prt).c��� .Qn•i�� l3r'2v�� ✓...iia <br />Partner/Officer Name (First Middle Last) DOB- <br />(partner/officer Name (First Middle Last) . DOB <br />f <br />Partner/Officer Name (First Middle Last) DOB <br />Intoxicating liquor licensees must attach a certificate of Liquor <br />must contain all of the following: <br />1) Show the exact licensee name (corporation, partnership, LI <br />2) Cover completely the license period set by the local city or <br />Circle One: (Yes No) During the past year has a summons bi <br />Workers Compensation Insurance is also required by all licen: <br />/ f <br />Workers Compensation Insurance Company Name: <br />I Certify that this license(s) has been approved in an official <br />City Clerk or County Auditor Signature <br />On Sale Intoxicatingg liquor licenseesm call also <br />121 <br />ui <br />application for the Buyers Card, please <br />(Form 9011-5/06) <br />-110- <br />p this form to certify the issuance of the following liquor <br />lay liquor licenses <br />sale malt liquor licenses <br />_ License Period From: Zp- 13 O i. To: frs - 30 ' a7 <br />Suspension Revocation Cancel <br />une) (Give dates) <br />n Li 3.2% On sale 3.2% Off Sale <br />3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />7 Social Security #i - r u 7 K R <br />Address 7 7'T h c•.. c` 3 31vr]CitY.ws <br />1 -7 A cc Home Phone <br />Licensee's MN Tax ID # Y1: V-70 <br />(To Apply call 651-296-6181) <br />• <br />the following for each partner/officer: <br />9FTI/6 y <br />Social Security # Home Address <br /># Home Address <br />Social Security # Home Address <br />Liability Insurance to this form. The insurance certificate <br />C, etc) and business address as shown on the license. <br />my licensing authority as shown on the license. <br />issued to the licensee under the Civil Liquor Liability Law? <br />Please complete the following: <br />sT Cliicice -Z.Ua• Policy # t� <br />Mg by the governing body of the city or county. <br />Date <br />(title) <br />a $20 Retailer Buyers Card. To obtain the <br />1., or visit our website at ww.dps.state.mn.us. • <br />w <br />