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PHONE 612 - 2966159 <br />MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIVISION <br />333 SIBLEV • ST. PAUL, MN 55101 <br />APPLICATION FOR CONSUMPTION AND DISPLAY (SETUP) PERMIT <br />PERMIT FEE $150.00 <br />IF NAME AND ADDRESS SHOWN ARE <br />NOT CORRECT, MAKE CHANGES IN <br />SPACES BELOW. <br />NOTE: ALL CLUB 'ON-SALE' INTOXICATING LIQUOR LICENSEE'S ARE EXEMPT FROM APPLYING. <br />Applicants Name Name (BuSu51ness, Partnership, Corporation) / Trade Name or DOA /' <br />//I/ 6 `/O N.G i; /41/ -I-N t. 6d &/C C..4 ,e7q yjB'I/ <br />Business Street Addre55 Or fax Number County Butietit Phone <br />1/ 3 3 f 5,V7- Cc?saa c4 RJ <br />C■y // <br />J/ ZT /2 ` no c/9 <br />PERMIT TYPE t <br />0 Private Club Y_rvumic Business <br />gesois? f 1 Y,had <br />Stale zI• Code <br />MN S —S//'7 <br />Type of Business (Restaurant, Dance Hall, etc.) <br />Name p1 Dullness Of Club Mandger <br />S /eLie al /. Alc <br />O1 0u `1 <br />WeJdrI;A) A74- // C:Afer; /, <br />Address 1 Manager / <br />//003.3 R 7.1 s/ 4) 7ate cSo73 <br />Address of Owner <br />Name of Bul101ng Owner / 4 <br />l vl on / «' . rkeel e e L. /1 r-Oa {{''h <br />ARE T.1€ CLUB OR BUSINESS PREMISES SEPARATE FROM ArWI <br />OTHER BUSINESS ESTABLISHMENT' <br />Vol '._JNo <br />()Y/ to le Se,,, u <br />HAS OR WILL A NON-INTOXICATING MALT <br />TO <br />TI-415 BUSINESS FOR THIS LOCATION. <br />S" - /tv LLr C/p <br />LIOVOR LIC NSE BLE ISSUED <br />Y 17No <br />15 APPLICATION <br />ORIGINAL 0 RENEWAL(.: T RANSFE0 <br />IF TRANS ER, FORMER LICENSEES <br />L <br />ES NAME AND BUSINESS TRADE NAME <br />.)oa c it e•-• J- k<> c-4 e r- /n.rr /4/4// <br />FOR A PUBLIC BUSINESS: <br />If a Panne/011p. State the Name and Address of Each Partner; If a Corporation. State the Name and Address of Each Of Iicer. <br />Bunne55 trine, /ol ncer 11II� <br />!WI irS .' V� c. n as o y <br />Buslnel5 Partner /Officer <br />7 <br />Address <br />aY/ W47, S/-4/ 5-n. <br />Address <br />Business Parmev01 fker <br />Addrest <br />FOR A PRIVATE CLUB <br />bate Club Organized <br />Number of Members <br />Amount 01 [duet <br />Membership Re oulremenit <br />Length of Ttme Club <br />Al Present Location <br />Is Club B rrldln9 <br />Owned o Rented' <br />DoeS Club Maintain LOCkert -1 <br />For Members To Store LIouOI' LIve, ENO <br />Club Officer/Director Name <br />Address <br />Club Officer /Director Name <br />Address <br />Club Of ncer /Direct or Name <br />Address <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 that the answers are true OI my own knowledge and understand hat the giving of False Information or the failure to give pertinent information <br />constitutes cause for revocation of thus perntl ANY PERMIT ISSUED HEREUNDER DOES NOT ALLOW THE SALE OF INTOXICATING LIQUOR. <br />/CA-s <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 />Approved — Chairperson Coen1y Bond or Reo resenlabve Dale <br />IF THE BUSINESS 15 LOCATED IN A MUNICIPALITY <br />Approved - Council President or Representative Date <br />PS 9007 (beat <br />S. arore — Auth zed Apotican1 <br />IF A CLUB ATTACH A COPY OF THE CONSTITUTION ANO <br />BYLAWS OF THE CLUB AND A CURRENT LIST OF <br />MEMBERS. <br />Page 92 <br />CASH <br />CHECK <br />