|
Minnesota Department of Public Safety
<br />LIQUOR CONTROL DIVISION
<br />190 5th St. E. Suite 105, St. Paul,MN 55101
<br />(612)296-6430 TTY(612)282-6555
<br />OFF SALE INTOXICATING LIQUOR LICENSE
<br />Ye: �'
<br />t1
<br />APPLICATION FOR
<br />No license will be approved or released until the S20 Retailer ID Card fee is received by MN Liquor Control
<br />Workers compensation insurance company.
<br />LICENSEE'S SALES & USE TAX ID # 45(.0
<br />Name (t) A U n r4 c L Policy# 03 I 10— CSC) M / 2,O a
<br />0 /'-/ L
<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 />iEi)c S Aril I' t'YR.
<br />Trade Name or DBA
<br />License Location (Street Address & Block No.)
<br />7Z(00 LAKE Jr,t;c.
<br />License Period
<br />From To
<br />Applicant's Home Phone
<br />City
<br />L i n)n / 4)< S
<br />County
<br />ANi< A-
<br />State
<br />CYh /U,
<br />Zip Code
<br />,5-0 Pi
<br />Name of Store Manager
<br />MOR 6A- eet AlA.y"ogre
<br />Business Phone Number
<br />DOB (Individual
<br />SOINIIIIM
<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 />WO , state
<br />incorporated
<br />incorporated
<br />No
<br />second
<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 0
<br />2. Describe premises to which license applies; such as (first floor,
<br />/ ST P L o r P4 n r ,,-/;';n)`1
<br />3. Is establishment located near any state university, state hospital, traidng school, reformatory or prison? 0 Yes .ArNo If yes
<br />state approximate distance. _ - -� )
<br />4. Name and address of building owner:
<br />'Pori sT LA-I(f 6 S O o2 S
<br />Pella Sim 0 .N.S0 rO 9.78% S e A•N ri r` A TP, iV .
<br />Has owner
<br />of building any connection, directly or indirectly, with applicant? 0 Yes N 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? 0 Yes g 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 tii:No If yes, give name and address of establishment.
<br />any right, title or interest in the furniture, fixtures or equipment for which
<br />N
<br />or indirectly,
<br />in any other liquor establishment in the state of Minnesota?
<br />
|