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PHONE 612 - 2966159 <br />MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIVISION <br />333 SIBLEY • ST. PAUL, MN 55101 <br />APPLICATION FOR CONSUMPTION AND DISPLAY (SE•UP) PERMIT c7 c/ <br />PERMIT FEE $150.00 <br />5179 <br />PUBLIC .R. / r_...•:.. .3 • 3 1 ! J <br />W NAME AND ADDRESS SHOWN ARE <br />NOT CORRECT. MAKE CHANGES IN <br />SPACES BELOW. <br />Joachim J. Koch <br />LeClaire Hall <br />433 E Little Canada Rd /::.md,Cx.-..y -�a- <br />t <br />S. Paul -, -MN- 55117 ✓•.•<'rGc <br />-c%Y . ! ,.-( /h I R.1 s 17. /1 7 <br />NOTE: ALL CLUB 'ON-SALE' INTOXICATING LIQUOR LICENSEE'S ARE EXEMPT FROM APPLYING. <br />/n f} e �..� 1 L�Lc? C, �� r <br />ADOlpeaants Narne (Busmen, Parinennlp. Coro •Ilan) ! Trade Name D // za_ Buslne» Sims] Aamees or Numper ao(u}py Bullnesa pnona <br />m4Am .ge_�i I �y 3e-aYGi <br />74/ <br />Type of ullness ( Reltaur atali Dante 4.11. etc.) <br />tT±Le (14/t/A -A /� /%'fiNh�• <br />City <br />PERMIT TYPE <br />Private Cluo Public Elusion, <br />Name of Business or Club Manager <br />\/ r /6 C, r <br />Zip code <br />CS) 2 <br />D �mo C' //4 // by A), d_d r✓ j - <br />Address of Manager <br />n2gCo A9YGY,¢c/r�. <br />Name Of Building Owner <br />e. /1/2 ..41 ARE THE CLUB OR BU INESS PREMI ES SEPARATE FROM ANY <br />OTHER BUSINESS ESTABLISHMENT? rl0 ONO <br />/ <br />Address of Owner <br />HAS OR ILL A NON.INTOXICATING MALI LIOUOR LICENSE BEEN ISSUED <br />TO THIS BUSINESS FOR THIS LOCATION? CF/" f—INo <br />15 APPLICATION <br />ORIGINAL IJ RENEWAL TRANSFER ❑ <br />IF TRANSFER, FORMER LICENSEES NAME AND BUSINESS TRADE NAME <br />FOR A PUBLIC BUSINESS: <br />II a Partnership, State the Name and Address of Each Pa (net; If a Corporation, State the Name and Address of Each Of Iicer. <br />Business Partner/Of cer <br />Address <br />Buunest Partner/Once, <br />Address <br />Butanes' Partner!officer <br />Address <br />FOR A PRIVATE CLUB <br />Date Club Organize° <br />Numbel of Members <br />Amount of Outs <br />Mernbers to 0eouiremenls <br />Lengln of Time Club <br />Al Present Location; <br />Is Club B riding <br />Owned O Rented, <br />Dees Club Maintain Lockers <br />For Members To Store Libuer! E <br />1 -1Vei ON. <br />Club Officee /U,retlor Name <br />Addrost <br />CIuD Of liter /Director Name <br />Address <br />Club 01 liter /Onect Or Name <br />AOOress <br />Has applicant; if partnership, any partner; if corporation, any officer or director; if club, any club officer or director, ever <br />had a license under the Minnesota Liquor Control Act revoked or suspended or been convicted for any violation of State <br />Laws or local ordinances; if so, give date and details <br />I hereby ceruly I hat the answers are true Of my own knowledge and understand <br />COnsn lules cause for revocalion of this pe•rno ANY PERMIT ISSUED HEREU <br />NO CONSIDERATION WILL BE GIVEN TO THIS APPLICATION <br />UNLESS APPROVED AS PROVIDED BELOW <br />IF THE BUSINESS IS LOCATED IN A COUNTY: . -. -. <br />ved — Chairperson Coemy Board or Representative Dale <br />IF H�/6USINESS IS LOCATED IN A MUNICIPALITY <br />Por,ved — Council President a Rep,Uenulive Date <br />Ps 9007 11,85) <br />Page 61 <br />that the giving GI lake inlormal ion or the failure IQ give pertinent information <br />HOER DOES NOT ALLOW THE SALE OF INTOXICATING LIOUOR. <br />%'7/ <br />Dale <br />IF A CLUB ATTACH A COPY OF THE CONSTITUTION AND <br />BYLAWS OF THE CLUB AND A CURRENT LIST OF <br />MEMBERSr <br />Ar,M1 <br />—14/S) <br />e FR <br />< SASEiY ;;11 <br />•Dc cocky, 4 <br />I <br />1' ht <br />\ 1 <br />CASH <br />CHECK <br />/SO •Od <br />