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Form No. 234% -State form 109 Election Systems and Software 1-800-800-8225 STATE OF MINNESOTA Combination Application for Retailer's (On -Sale) (Off -Sale) 3.2 Beer Lino Lakes Ilk (Name of licensing authority (county) (city) County of Anoka I St. Joseph Parish , of the city, or town of Lino Lakes county of Anoka State of Minnesota, hereby make application for a Retailer's (On -Sale) (Off -Sale) 3.2 Beer License to sell such 32 Beer under and pursuant to an ordinance (resolution) passed by city council, county board of, : and Chapter 340, Minnesota Statutes 1945, as amended, providing for licensing and regulating the sale of 32 Beer. During the past five years, my residence has been as follows: 171 Elm Street I was born at NV p 1 am a (native) (naturalized) citizen of the United States. I am married. My (wife's) (husband's) name and address is 1 am proprietor. Firm was incorporated 1 891 in the state of Mi nnegota Corporation is authorized to do business in Minnesota. License is for 171 Elm Street (street) (highway) located as follows: The license will be in connection with Eventide which has been in operation years X110 The establishment is located on the 1st floor. The business premises are owned by St. Joseph Parish . he am taxes on the property are not delinquent. not engaged in the retail sale of intoxicating liquor. 1 have .,01- had an application for license rejected as follows: 1 have never been convicted of a felony nor of violating any National or state liquor law or local ordinance relating to the manufacture, sale or transportation, or possession for sale or transportation of intoxicating liquor. Gambling or gambling devices will not be permitted on the licensed premises. 1 am the owner of the leasehold, furniture, fixtures, and equipment in the premises for which the license is applied, except N/A 1 have no intention or agreement to transfer the license to another person. 1 submit the following names of persons, including a bank, for reference, with whom I have had business relations as follows: I intend to engage in the sale of intoxicating liquor and will have a Federal Occupational Tax Receipt in accordance with the ordinance governing this license. My Federal Tax Stamp Receipt is No I will comply strictly with the provisions of the ordinance relating to the sale of soft drinks for "mixing" purposes and will serve patrons In full view of the public. 1 agree to waive my Constitutional Rights against search and seizure and will freely permit peace officers to inspect my premises and agree to the forfeiture of my license if found to have violated the provisions of the ordinance (resolution) providing for the granting of this license. 1 hereby solemnly swear that the foregoing statements are true and correct to the best of my knowledge and that I agree to comply with all the provisions of the ordinance under which this license is granted. Subscribed and sworn to before me this Ia � S,_�. A. .t-.4.4..1-mom- -- day of - q f1 L f C , Year G rJ 1 Applicant's Signature � �-�. \ -1- lc c. clay .v.... .....o. L'Sr. M. ttOGSTAv s:,, NOTARY PuSUC-MINNES3TA �y Licenses may be issued only to persons who are citizens. f thelittited States and who are of @. d moral character and repute, who h attained the age of 21 years and who are proprietors of ttte' sfebligFrrne'fiffiti �hlcff h'i.ficeria s are issued. Laws 1949, c. 700.