|
°'
<br />a 1
<br />Minnesota Department of Public Safety
<br />LIQUOR CONTROL DIVISION "'""�'
<br />190 5th St. E., Suite 105, St. Paul, MN 55101 ,`r . ,
<br />612 296-6430 TTY(612)282-6555 '
<br />OFF SALE INTOXICATING LIQUOR LICENSE
<br />APPLICATION FOR
<br />No license will be approved or released until the 520 Retailer ID Card fee is received by MN Liquor ControL
<br />Workers compensation insurance company.
<br />LICENSEE'S SALES & USE TAX ID # 456.)
<br />Name 11)A L «S r4 (t Policy# 03 % b ✓ C)C) -- / a O,3 2 _
<br />01/ L/.9.,
<br />To apply for sales tax #, call 296-06181 or 1-800-657-3777
<br />a partner shall execute this application.
<br />If a corporation, an officer shall execute this application If a partnership,
<br />Licensee Name (Individual, Corporation, Partnership)
<br />S%£i)c', 3- Arh.f (_7'R.
<br />Trade Name or DBA
<br />License Location (Street Address & Block No.)
<br />7( LAKE" n r; uee:
<br />License Period
<br />From To
<br />Applicant's Home Phone
<br />City
<br />L. i n;t-) / 4!f.S
<br />County
<br />ANo{{ A
<br />State
<br />C) /U;
<br />Zip Code
<br />5.-0)(-/
<br />Name of Store Manager
<br />I'(9R64e.ec nJfv •-a, e
<br />Business Phone Number
<br />DOB (Individual
<br />Applicant)
<br />If a corporation, state name, date of birth, 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 />DOB
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1. If a corporation, date of incorporation
<br />capital . If a subsidiary
<br />, state
<br />incorporated
<br />incorporated
<br />No
<br />second
<br />Lei ;-.v`f
<br />so state
<br />in , amount paid in
<br />of any other corporation,
<br />. If
<br />and give purpose of
<br />is corporation
<br />building, so state.
<br />corporation
<br />under the laws of another state,
<br />floor, basement, etc.) or if entire
<br />authorized to do business in the state of Minnesota? 0 Yes ❑
<br />2. Describe premises to which license applies; such as (first floor,
<br />r57- f Curs . - P4INT 0-F Atli
<br />3. Is establishment located near any state university, state hospital, training school, reformatory or prison? 0 Yes .2'No If yes
<br />state approximate distance. 1
<br />4. Name and address of building owner:
<br />'Fun's i LA k f fig D '5
<br />ri 6 S : m D .) So 'v 9 ? R 5.5 C. An) rJ r' A TR, ,
<br />Has owner
<br />,i
<br />of building any connection, directly or indirectly, with applicant? 0 Yes !t No -�'�
<br />a member of the governing body of the municipality in which this license
<br />5. Is applicant or any of the associates in this application,
<br />is to be issued? ❑ Yes tri' No If yes, in what capacity?
<br />6. State whether any person other than applicants has
<br />license is applied and if so, give name and details.
<br />7. Have applicants any interest whatsoever, directly
<br />0 Yes EtNo If yes, give name and address of establishment.
<br />any right, title or interest in the furniture, fixtures or equipment for which
<br />il) 0
<br />or indirectly,
<br />in any other liquor establishment in the state of Minnesota?
<br />
|