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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- 296 -6979 Fax 651- 297 -5259 TTY 651- 282 -6555 <br />www.dps.state.mn.us <br />Application for Optional 2 AM Liquor License <br />License type code: 2AM License Expiration Date ID# <br />(For Otttce Use Only) <br />Licensee Name: <br />c�rQ rn c -57\ <br />Trade Name: 13 cA-ThV ec\C AVQrf (i3O <br />Licensed Location Address: dg21�' 0 0 N— R C e Sk- - <br />City, State, Zip Code: Ls IT \ CG\'\ G`4 , <br />Business Phone: ! A-- <br />If the above named licensee is a corporation, partnership, or LLC, complet- the following for each partner /officer: <br />Partner /Officer Name (First Middle Last) <br />Social Security # Home Address <br />Partner /Officer Name <br />(First Mi as DOB Social Security # Home Address <br />Partner /Officer Name (First Middle Last) <br />DOB <br />Social Security # Home 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 />❑ $300 2 AM license fee <br />❑ $750 2 AM license fee <br />❑ $1,000 2 AM license fee <br />❑ $200 2 AM license fee - <br />El $200 2 AM license fee - <br />- Up to $100,000 in on sale gross receipts for alcoholic beverages <br />- Over $100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages <br />- Over $500,000 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 />(I certify that the city or county of approves the sale of alcoholic beverages until 2 AM) <br />Licensee Minnesota Tax ID Nu •ber (Required) <br />Licensee Signa <br />certify that I have ans • d the above questions truthfully and correctly) <br />Date <br />Licensee: Prior to submitting this application to the Alcohol and Gambling Enforcement Division, it must be <br />signed by your local city or comity licensing official. <br />(2AM -1 1/05) <br />5 <br />