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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLCS'G ENFORCEMENT DIVISION <br />44; Cedar Sl, Suite 133, St Paul, MN 55101-5133 <br />Fax (651)297-5259 <br />(651)296-6979 TTY (651)282-6555 <br />CERTIFICATION OF AN ON SALE AND/OR SUNDAY LIQUOR LICENSE <br />No license wUl be approved or releaaed untU the W .j <br />Workers Compensation Insurance Company l^c/ __________________Policy # 0 f ------------ <br />LICENSEE'S SALES & USE TAX ID # ^ 1 To apply for sales tax number, call (651)296-6181 or 1-800-657-3777 <br />CITY OF Or oho <br />ISSUING AUTHORITY <br />COUNTY OF <br />Licensee Name (Corporation, Partnership, LLC, Individual) DOB <br />^\a- ZDuunt! ^hk-ef‘iT [2 <br />Social Security #Trade Name or DBA <br />\i I ou^u. <br />Business <br />License “Typ t <br />Dn Sal^ <br />OiTSaRT-t« <br />License Typ e (Check one or both) <br />( Sunda^ <br />Fee Paid to tiny <br />City <br />C> <br />FSatTLicense Number <br />License Period / . <br />From Vt/a.g"»-‘ To ^ ^ <br />II Sunday License Number <br />*H006, CC __________ <br />a corporation, partnersnip, LLC, state the name date ot oirth, social security »and address ol each partner or olHccr. <br />Fee Paid to City <br />CC <br />Zip Code . <br />.13-4?/ <br />County <br />Business <br />Partner/Ofl'iccr Name (First, middle and last;DOB Title Address <br />Parmer/Officcr Name (First, middle and last)DOB SSI#Title Address <br />Partncr/Officcr Name (First, middle and las:)DOB SSI#Title Address <br />The Licensee must have one of the following; <br />Check one <br />(ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />Liquor Liability Insurance (Dram Shop) - 550,000 per person; 5100,000 more than one person; 510,000 Property Destruction; <br />S50.000 and 5100,0<X) for loss of means of support. <br />B. A bond of a surety company with rrinimum coverage as specified above in A. <br />C. A certificate from the State Treasurer that the licensee has deposited with the State, Trust Funds having a market value of SIOO.OOO <br />r*^c^ f\r ^^rnrift^c <br />Yes (^N^^uring the past license year has a sumrr.ons been issued under the Liquor Civil Liability Law (Dram Shop)? <br />If yes, attach a copy of the summons.________________________ <br />leck those items that apply Circle one <br />Transaction T>pcCNc^ Rcvoke'Canccl <br />Transfer Suspension <br />Suspcnd/Revoke-'Cancellcd <br />From To <br />Transfer of ownership from (Name and Address) <br />I certifk that this license was approved in an official meeting by the governing body of the city or county. <br />City Clerk’s Signature Date <br />IMPORTANT NOTICE <br />All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp U issued b> the Bureau Alcohol, <br />Tobacco and Firearms. For information call (651)290-3496 __________________(PS 9011-98)_____________