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Minnesota Departrneut of Public Safetti• <br /> ALCOHOL AND GAMBLLNG E`TORCEMENT <br /> 44514iunesota Street,Suite r21?.St.Paul.%TN 55101 <br /> OFFICE(631)?01-7507 FAX(651) 9%52259 TTY i6511 2182-6555 <br /> DPS,MN.GOV <br /> .-UPLIC'.kTION FOR OFF SALE MO-WATLiG LIQUOR LICENSE <br /> No license will be approved or released until the S20 Retailer ID Card fee is received <br /> PLEASE CO-NiPLETE THIS APPLICATION E\ITS ENTIRETY. <br /> L�C'OMPLETE APPLICATIONS N17ILL BE RETUR\`ED WITHOUT ACTION, <br /> Liteeisee's'.M Sn es and Use Tax ID 77�C�2 To apply for a l D sales aid Use tax ID 0(I 196.61SI <br /> Licensee's federal Tax ID# ] _ //A ► ,Z Uceasee=mu.t register with'be Frdent Tnx and Trade Bureau('C' ). <br /> for iafornrarion call(513)684-2979 or t-6004374864 <br /> Applicant: <br /> Licensee Name(Business.Parhrer hip.Corporation) Bminess Name( A) <br /> A V 1 X-O T 1- 44C, !JC Q _'TZ L-[ <br /> Licensee Locition i Filvslcai Addreis) :4icense err <br /> .3 Oo Froili / �To J 7 <br /> Citt Cottait< State Zip Coda <br /> 0044S 1 u C MN <br /> E-mail Address Bustu ss Phone Number Applicant's Home Phone <br /> EC 0- Ti 3- 1 S S �C7 to 79 z <br /> If a Corporation.LLC,or Partnership-state name,date of birth.Social Security#address,title.and Percept Ottved by each officer. <br /> Fannex 0111cer 7 rrs,5113tue,ias ) Me rercelit AC WI;, kAtt, 15D e rp o'e <br /> 719AN �d�, . 3 S C�ov► Plc <br /> l41'� ZO I C Z (1E5/ r l t1�►td5 t l�r47 ► Q CK#2 <br /> Partner Officer(First,middle,last) Title Percent ;address.C'im State.Zip Code <br /> Partner Officer(First.middle.last) DOB SS# Mle Percent address.C-,t}. State.Zip Code <br /> Parz-ner Officer(First.middle.last) DOB SS# Title Percent Address. City.State_Zip Code <br /> 1. If a corporation, date of incorporation state incorporated in If <br /> a subsidiar-of any other corporation. so state <br /> If 111corporared mider the laws of another State. is corporation authorized to do business in the state of Mintlesota? <br /> Lye$ LNo <br /> . Describe premises to which license applies, sucli as (first floor. second floor. basement.etc.)or if entire building, <br /> so state. <br /> 3. Is establishinent located clear any state university.state hospital. training school.refonllatory of prison' <br /> ,fires No. If yes.state approximate distance. <br /> Name S address of building owner <br /> Has owner of building any connection. directly or indirectly,with applicant' Lyes "o <br />