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Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br />444 Cedar St., Suite 222, St. Paul, MN 55101
<br />(651) 201 -7507 FAX (651)297 -5259 TTY(651)282 -6555
<br />W WW.DPS.STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the $20 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name tJ (F- • Policy 4
<br />Licensee's MN Sales and Use Tax ID #! U "9- To apply far a MN sales and use lax ID 8,, call (651) 296 -6181
<br />Licensee's Federal Tax ID 6 Q
<br />If a corporation; an officershall execute this dpplication If a partnership, a partner shall execute this application.
<br />Licensee Name (Individual, Corporation, Partnership,
<br />L,i.._IC. l_.('r0ALA... L-, )4.
<br />LLC)
<br />c
<br />e L "�
<br />Social Security #!
<br />I
<br />!cense Period
<br />From To
<br />Trade Name or
<br />T 1 /a(uz.,
<br />((:)-1,5()--A;2,
<br />DBA
<br />(5 Lrro0,2
<br />App]i ant's Home Phc e #!
<br />C cf I' CYs te- / OI'rO
<br />License eLLocation (Street Address & Blo is No.)
<br />a- �- 6 Q Q i c_e ]
<br />City
<br />Z__ ;'fi )e Ca,uA. c. U,
<br />County ,
<br />WI5-e
<br />%1,/
<br />Zip Code
<br />c 113
<br />Name of Store Manager
<br />Business Phone Number
<br />DOB (Individual Applicant)
<br />If a corporation or LLC state name, date oflneth, Social Security 4 address, title, and shares held by each officer. If a partnership, state
<br />names, address and date of birth of each partner.
<br />Partner Officer (First, middle, last)
<br />C6[0(J Cc UO,!%J
<br />DOB SS #I
<br />_
<br />Title
<br />ow,Ue,C
<br />Shares
<br />�j
<br />/0070
<br />Address, City, State, Zi ode
<br />S-244,9176, GJn .e.
<br />Partner Officer (First, middle, lax)
<br />DOB SS4
<br />Title
<br />Shares
<br />Address, City, State, Zip Code /2
<br />Partner Officer (First, middle, last)
<br />DOB 5514
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB 554
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1. If a corporation, date of incorporation
<br />capital . If a subsidiary
<br />/0-- '0? -2 0 11, state incorporated
<br />so state
<br />floor,
<br />in A4 t Ais✓C Sc-I- ✓i- amount paid in
<br />of any other corporation,
<br />. If incorporated
<br />and give purpose of
<br />corporation
<br />under the laws of another state, is corporation
<br />basement, etc.) or if entire building, so state.
<br />authorized to do business in the state of Minnesota? 0 Yes it No
<br />2. Describe premises to which license applies;/ such as (first floor, second
<br />_'I-1 (..,t; L /C.'_ C. FiIT/ ;c �� Ldo
<br />3. Is establishment located near any state university, state hospIttl, training school, reformatory or prison? DYes F\No If yes state
<br />approximate distance.
<br />4. Name and address of building owner.
<br />Has owner of building any connection, directly or
<br />5. Is applicant or any of the associates in this application,
<br />to be issued? 0 Yes p\-No if yes, in what capacity?
<br />indirectly, with applicant? 0 Yes 6,No
<br />a member of the governing body of the municipality in which this license is
<br />6. State whether any person other than
<br />is applied and if so, give name and
<br />applicants has any right, title or interest in the furniture, fixtures or equipment for which licenst
<br />details. / ✓(i
<br />7. Have applicants any interest whatsoever, directly
<br />KTYes G No If yes, give name and address of establiss
<br />or indirectly, in any other liquor establishment in the state of Minnesota.?
<br />ent. C /-%t:“ C /lao C i ux4 A°s Ee vii/C` C'-t A
<br />I f%✓ad
<br />6 5 % i1,.1 P L 12.1.
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