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MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />PHONE 612-296-6570 LIQUOR CONTROL DIVISION <br />333 SIBLEY • ST. PAUL, MN 55101 <br />APPLICATION FOR CONSUMPTION AND DISPLAY (SET -UP) PERMIT <br />PERMIT FEE $150.00 <br />Little Canada Hall Inc. <br />Little Canada Hall <br />433 E Little Canada Rd <br />Little Canada MN 55117 <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 Full Name (Business, Partnership, Corporation) <br />Z` <br />, /e 677 x?((JP //4f/ .T <br />DOB <br />Trade Name or DBA <br />4, /t /r. (Gflwr /f, /-1417/ <br />Business Street Address or Box Number <br />A/ 33 E. L; /-*/e. re-, /4 n( /LX <br />County <br />/,.5, <br />State ' / ( <br />M/" <br />Business Phone <br />( ci) 42(Y -..3CS -C. <br />Zip Code <br />537/7 <br />City �y j <br />L/. / / /L• ec7 ✓/c,.% <br />PERMIT TYPE <br />❑Private Club ❑ Public Business <br />Type of Business (Restaura nt, Dance Hall, etc-) <br />�Q A( ;v /lilt(, ((np Ter/N7 <br />Full Name of Business or Club Manag� <br />..../eve 17 K �C>,r 1- Al c /Jon o-e 4 <br />DOB <br />-77/1/ 6, <br />Address of Manager <br />/6 033 /Y 8-74 -5/ Zit4Le /4(4/- ll6t, 5.50 3 <br />!Jame Of Building Swner J <br />voHS J, fit c aJo yr 0;. <br />Address of Owner <br />a`/( C(14 le /en■ /9 ✓-e s - "la/ GkvSt /O <br />A E THE CLUB OR BUSINESS PREMISE ARATE FROM ANY <br />OTHER BUSINESS ESTABLISHMENT? • p( <br />es 0 N <br />/ <br />HAS THERE OR WILL THERE BE A NON- INTOXICATING MALT LIQUOR LICENSE ISSUED <br />TO THIS BUSINESS AT THIS LOCATION? <br />Yes 0 N <br />I5 APPLICATION <br />^ <br />ORIGINAL LI RENEWAL- TRANSFER 0 <br />IF TRANSFER, FORMER LICENSEES NAME AND BUSINESS TRADE NAME <br />FOR A PUBLIC BUSINESS • <br />If a Partnership, State the Name and Address of Each Partner; If a Corporation, State the Name and Address of Each Officer. <br />Business Partner /OHlcer /Full Nem % <br />TG[rinaRc 7( 62fr rJn..r l <br />DOB <br />!01/4 -7 <br />Address <br />�// <br />-> Cl( Ct/‘d 6e..r! /4 ✓z : /92 ✓( S—S/o1 <br />Business Partner/Officer/Full Name V <br />DOB <br />Address / <br />Business Partner /Officer /Full Name <br />DOB <br />Address <br />CASH <br />CHECK <br />Page 5 <br />(SEE REVERSE SIDE) <br />