Minnesota > Statewide > Alcohol And Gambling Enforcement Division
Certification Of An On Sale Liquor License 3.2 Liquor License Or Sunday Liquor License 9011 - Minnesota
| Certification Of An On Sale Liquor License 3.2 Liquor License Or Sunday Liquor License Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide . |
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Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 444 Cedar Street, Suite 133, St. Paul, MN 55101-5133 Telephone 651-201-7507 Fax 651-297-5259 TTY 651-282-6555 Certification of an On Sale Liquor License, 3.2% Liquor license, or Sunday Liquor License Cities and Counties: You are required by law to complete and sign this form to certify the issuance of the following liquor license types: 1) City issued on sale intoxicating and Sunday liquor licenses 2) City and County issued 3.2% on and off sale malt liquor licenses Name of City or County Issuing Liquor License_________________ License Period From:_____________ To:______________ Circle One: New License License Transfer_______________________ Suspension Revocation Cancel _______________ (former licensee name) (Give dates) License type: (circle all that apply) On Sale Intoxicating Sunday Liquor 3.2% On sale 3.2% Off Sale Fee(s): On Sale License fee:$________ Sunday License fee: $________ 3.2% On Sale fee: $_______3.2% Off Sale fee: $______ Licensee Name:____________________________________ DOB____________ Social Security #________________________ (corporation, partnership, LLC, or Individual) Business Trade Name____________________________ Business Address______________________ City__________________ Zip Code________ County__________ Business Phone_____________________ Home Phone___________________________ Home Address________________________ City_________________________ Licensee's MN Tax ID #________________ (To Apply call 651-296-6181) Licensee's Federal Tax ID #____________________________ (To apply call IRS 800-829-4933) If above named licensee is a corporation, partnership, or LLC, complete the following for each partner/officer: _______________________________________________________________________________________________________ Partner/Officer Name (First Middle Last) (Partner/Officer Name (First Middle Last) Partner/Officer Name (First Middle Last) DOB DOB DOB Social Security # Social Security # Social Security # Home Address Home Address Home Address ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Intoxicating liquor licensees must attach a certificate of Liquor Liability Insurance to this form. The insurance certificate must contain all of the following: 1) Show the exact licensee name (corporation, partnership, LLC, etc) and business address as shown on the license. 2) Cover completely the license period set by the local city or county licensing authority as shown on the license. Circle One: (Yes No) During the past year has a summons been issued to the licensee under the Civil Liquor Liability Law? Workers Compensation Insurance is also required by all licensees: Please complete the following: Workers Compensation Insurance Company Name:___________________________ Policy #___________________________ I Certify that this license(s) has been approved in an official meeting by the governing body of the city or county. City Clerk or County Auditor Signature_______________________________________ Date_____________________ (title) On Sale Intoxicating liquor licensees must also purchase a $20 Retailer Buyers Card. To obtain the application for the Buyers Card, please call 651-215-6209, or visit our website at www.dps.state.mn.us. (Form 9011-5/06) American LegalNet, Inc. www.FormsWorkflow.com
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