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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 222, St. Paul, MN 55101 -5133 <br />Telephone 651- 201 -7507 Fax 651- 297 -5259 TTY 651 -282 -6555 <br />v vw.dps.state.mn.us <br />Application for Optional 2. AM Liquor License <br />License type code: 2AM License Expiration Date ID# <br />Licensee Name: /.. / / 1 /ct_t <br />IV. <br />(F&Cface Use Only) <br />Trade Name: / -/ 17 / a- <br />V C.//C- / /4 /i -.l /m) <br />Licensed Location Address: /?- - (: /i.,:•7 <br />City, State, Zip Code: <br />c d7 ;'V <br />/ <br />Business Phone: ZS' , ,! ' 1 r A, ,e y-/ 1,", 1 <br />_2 4 � , / 17/ :- 7 7/7 <br />11111e above named licensee is a corporation, partnership, or LLC, complete the followin <br />ach partner /officer: <br />Partner /Officer Name (First Middle Last) DOB Social Security it Home Address <br />Farmer /Officer Name (First Middle Last) DOB <br />Social Security N <br />Home Address <br />Partner /Officer Name (First Middle Last) DOB Social Security it <br />Horne Address <br />Licensee must report previous 12 month on sale alcoholic beverage gross receipts by checking one of the boxes <br />below. Next to the box you check is your 2 AM license fee. Make check payable to: Alcohol and <br />Gambling Enforcement Division (AGED). Mail this application and check to : AGED, 444 Cedar St., Suite <br />133, St. Paul, MN 55101 -5133. <br />.W $300 2 AM license fee - <br />❑ $750 2 AM license fee <br />❑ $1,000 2 AM license fee <br />❑ 5200 2 AM license fee - <br />❑ $200 2 AM license fee <br />Up to $100,000 in on sale gross receipts for alcoholic beverages <br />- Over 5100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages <br />- Over 5500,000 in on sale gross receipts for alcoholic beverages <br />3.2% On Sale Malt Liquor licensees or Set Up license holders <br />- Did not sell alcoholic beverages for a full 12 months prior to this application <br />Yes ❑ No Does your city or county licensing official allow the sale of alcoholic beverages until 2 AM? <br />City Clerk /County Auditor Signature Date <br />(1 certify that the city or county of approves the sale of alcoholic beverages until 2 AM) <br />Licensee Minnesota Tax ID Number (Required) <br />Licensee Signature ( ( K. 2/' V 2 ' Date <br />(7 certify that 1 have answered the above OW= truthfully and correctly) <br />Licensee: Prior to submitting this application to the Alcohol and Gambling Enforcement Division, it must be <br />signed by your local city or county licensing official. <br />(2AM -5/06) <br />2 <br />