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Minnesota Department of Public Safety
<br />ALCOHOL ANI) 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,SI'A'CL-..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the S20 Retailer ID Card fee is received
<br />Workers compensation insurance company, Name Policy t!
<br />Licensee's MN Sales and Use Tax II) i! To apply for a AN sales and usu Fax ID it, call (65)) 2966/81
<br />Licensee's Federal Tax 11) t!
<br />If a corporation, an officer shall execute this application
<br />If a partnershiU, a Uartner shall execute this application.
<br />Liiceennse°Name (Individual, Corporation, Partnership, LLC)
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<br />..611CC..!tOnti
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<br />SocialSceurityil
<br />Trade
<br />NameorDBA
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<br />4-lC{' -sec
<br />License Location (St 'e Address & 131ock No.) �[
<br />T 70 i'\ IC'l.C:, , 5�-iCee-*
<br />License Period
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<br />Applicant's Home Phonje /I
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<br />Slate
<br />Int!
<br />Zip Code
<br />.�-.5 //3
<br />Nan n'of++Store Manager
<br />C 9" ' PtektSu A
<br />Business Ph fie Number
<br />DOB (Individual Applicant)
<br />If a corporation or LLC state name, date of birth, Social Security i/ address, title, and shares held by each officer. If a partnership, state
<br />names, address and date of birth of each partner.
<br />)ar ter Officer (First, middle, last)
<br />?-,NA s.., Le,n1 x-� II C�'(.SC r�
<br />Title
<br />e, t..,tJ inc. t"
<br />Shares
<br />160`11 0
<br />Address, City, State, Zip Code
<br />i'"Hlct.f ;.il.
<br />i�oiev t t ie mN i>.S l r a
<br />Partner Officer (First, muddle, last)
<br />D013
<br />551!
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (first, middle, last)
<br />1)013
<br />SS!!
<br />fide
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS)!
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1f a corporation, date of incorporati in 1 1 _. Z.3 - t 3 state ii corpm'atcd in l� os,-, , amount paid in
<br />capital . If a subsidiary of any other corporation , so state and give purpose of
<br />corporation . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? 0 Yes :2 No
<br />2. Describe premises to which license applies; such as (first floor, second floor, basement, etc.) or if entire building, so stale.
<br />3. Is establishment located near any state university. state hospital, training school, reformatory or prison? r:Yes'No If yes state
<br />approximate distance. •
<br />4. Name and address of building owner: OA ]tit �\` "A' it' (\ (0S k 2.'1 Ce . %'.1'-1 U (c
<br />Has owner of building any connection, directly or indirect y, with applicant? it Yes 4a10
<br />5, Is applicant or any of the associates in this application, a member of the governing body ol'the municipality in which this license is
<br />to be issued? 0 Yes 7tTh If yes, in what capacity?
<br />6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, give name and details. SLC
<br />7. Have applicants any interest whatsoever, directly or indirectly, ip any other liquor establishment in the state of Minnesota?
<br />'es 11 No If yes, give name and address of establishment. " 1 `--tc`k!ur• t�C-({etJc1ceX 1C1CC,t-clef jdlitti
<br />R .. i r .
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