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<br />Minnesota Department of Public Safety otFs; .
<br />LIQUOR CONTROL DIVISION�190 5th St. E., Suite 105, St. Paul, MN 55101 ��t !
<br />(612)296-6430 TTY(612)282-6555�._t5,;'
<br />OFF SALE INTOXICATING LIQUOR LICENSE
<br />'\„.
<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 #
<br />Name ?E /l) b i r Policy#
<br />PA)() I t1),..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 />Lice Name (Individual, Corporation, Partnership)
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<br />Trade Name or DBA
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<br />License Location (Street Address & Block No.) 1
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<br />License Period
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<br />From >' /` r ;'j / 7 To i a/Y /
<br />Applicants Home Phone
<br />.: --3-.k&
<br />((� 01/4
<br />City
<br />Li ,(.)l' ZgO,! 1=s 77//t'
<br />County
<br />/6'C`�-!
<br />State
<br />/77/f.1
<br />Zip Code
<br />557/
<br />Name of tore Manager
<br />(%1t_/ . S.,, '_1 77 -Ce f`
<br />Business PhoneLNumber
<br />(t,)) 7J yU.f °
<br />DOB (Indivvidual Applicant)
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<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 />r , o , state
<br />incorporated
<br />incorporated
<br />No
<br />second
<br />1 y-�
<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 />-i" %, c 4
<br />authorized to do business in the state of Minnesota? ❑ Yes 0
<br />2. Describe premises %- C:' S' to�hirch licen applies; suc as (first floor,
<br />f--, 1) b C:' , (, IG' es - 4
<br />3. Is establishmenklocated near any state university, stat hospital, training school, Jeformatory or prison? [?Yes ❑ No If yes
<br />state approximate distance. d .•',, /c S — (/L)41 `i9 5 , L=am re -le -F -e e r' /
<br />4. Name and addres of building owner:
<br />3 `` t/
<br />/ . I'. '-) 1141 CS ('1 f - 6 ' k ,,PV/ 4' / /7 /5 /%f Ai
<br />Has owner
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<br />of building any connection, directly or indirectly, with /pplicant? 0 Yes WI/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 C(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 [p'l'lo If yes, give name and address of establishment.
<br />any right, title or ' terest in the furniture, fixtures or equipment for which
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<br />or'fhdirectly,
<br />in any other liquor establishment in the state of Minnesota?
<br />
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