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Minnesota Department of Public Safety
<br />ALCOHOL AND 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 W W.DPS.STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the 520 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name
<br />Licensee's MN Sales and Use Tax ID #
<br />Licensee's Federal Tax ID #
<br />If a corporation, an officer shall execute
<br />Policy #
<br />To apply for a MN sales and use tax ID #, call (651)296-6181
<br />this application If aa
<br />Licensee
<br />Licensee Name (Individual, Corporation, Partnership, LLC)
<br />Lk -77-11 c,
<br />Social Security # Trade
<br />Name or DBA
<br />1 \\5 l _,�t,l> >'
<br />License Location (Street Address & Block No.)
<br />,:-P7o C G- 54
<br />icense Perio /
<br />,r
<br />From3/" To 4/3(i/l i
<br />/A , plicant's me Phone #
<br />tG .S/—j.s(< S 74,13 6a
<br />City
<br />Li7` C Cw..G&
<br />County
<br />Raitnse.y
<br />State
<br />4W)
<br />Zip Code
<br />,$._.113
<br />Name of Store Manager
<br />Mali (tt 1)
<br />Business Phone Number
<br />65/ -VP/ 5757
<br />DOB (Individual Applicant)
<br />Da corporation or LLC state nam , date of birth, Social Security # address, title, and shares held by each officer. If a partnership, state
<br />names, address and date of birth of each partner.
<br />Partner Officer (First, middle, last)
<br />nikadu In v
<br />SS#
<br />Title
<br />o» - e '
<br />Shares
<br />5U
<br />Address, City, State, Zip Code
<br />138ynice<4.w+ ssi.ead
<br />Partner Officer (First. middle, la
<br />La 19CYrt i.ce. "nt'.4-0
<br />DOB
<br />NIIIams
<br />SS/4
<br />Title
<br />rosin
<br />Shares
<br />Ski
<br />Address, City, State, Zip Code
<br />/alt/ Nft, si -F s4-1 5
<br />Partner Officer First, middle, last)
<br />DOB
<br />SSP
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Panner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />If a corporation, date of incorporation /JP 11 / / stale incorporated in MN amount in
<br />paid
<br />capital . If a subsidiary of any other corporation, so state and of
<br />give purpose
<br />corporation . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? 0 Yes 'XNo
<br />2. Describe premises to whiehlicense applies; such as (first floor, second floor, basement, etc.) or if entire building, so state.
<br />”uhf
<br />3. Is establishment located near any state university, state hospital, training school, reformatory or prison? :Yes jNo If yes state
<br />approximate distance.
<br />1/
<br />4. Name and address of building owner dila U C - vGtnn,j
<br />Has owner of building any connection, directly or indirectly, with applicant? '_0 Yes No
<br />5. Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license is
<br />to be issued? 0 Yes (\No 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 licenst
<br />is applied and if so, give name and details. /2 0/76-
<br />//%G7.
<br />7.Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />0 Yes 1i'No If yes, give name and address of establishment.
<br />
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