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Alcohol & Gnmhlin, End. O."M <br />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 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 <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: 1) City issued on sale intoxicating and Sunday liquor licenses <br />2) City and County issued 3.2% on and off sale malt liquor licenses % <br />Name of City or my Issuing Liquor License�lJd IA�1-ttn License Period From: 1o/��"� To: "31O0 <br />Circle On : New License License Transfer Suspension Revocation Cancel <br />(former licensee name) <br />License type: (circle all that apply) On Sale Intoxicating <br />Fee(s): On Sale License fee:$ Sunday License fee: $ <br />Licensee Name: R�N f DOB <br />(corporation, partnership, LLC, or Individual) <br />(Give dates) <br />Sunday Liquor 3.2% 3.2% Off Sale <br />3.2% On Sale fee: $ 3.2% Off Sale fee: $ <br />Social Security # <br />Business Trade Name Hwf-1, ocd SUh s Business Address I&I;ad NW City Iyc.m &tA�1�_ <br />Zip Code5SIQ- County Business Phone L09- L0N-SQW-- Home Phone <br />Home Address <br />City <br />icensee's Federal Tax ID # <br />(To apply call IRS 800-829-4933) <br />Licensee's MN Tax 1D # q 2,0 025-24 <br />(To Apply call 651-296-6181) <br />If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: <br />Partner/Officer Name (First Middle Last) <br />Social Security # <br />Home Address W111UalYyy,(SPy-q <br />(Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <br />Partner/Officer Name (First Middle Last) DOB Social Security # Home Address <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 exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. <br />2) Cover completely the license period set by the local city or county licensing authority as shown on the license. <br />Circle One: (Yes No During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? <br />Workers Compensation Insurance is also required by all licensees: Please complete the following: <br />Workers Compensation Insurance Company Name-.4XUSW lnsu-YA. tCD �U Policy #1.(1C.k.--;�-q I` qGSRs'+ <br />1 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 />*n Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the <br />application for the Buyers Card, please call 651-201-7504, or visit our website at wwwdps.state.mmus. <br />(Form 9011-5/06) <br />