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City of St. Anthony <br />3301 Silver Lake Road <br />St. Anthony, MAT 55432 <br />(612)789-8881 <br />Fee: <br />Intoxicating Li iwr & Nine <br />Sundav <br />APPLICATIONFOR ON -SALE <br />LNTOYICATING LIQUOR & WINE LICENSE <br />$8 000 <br />S 200 <br />1. <br />Receipt # _ 17 <br />License <br />MN Tax 11)#103.5,5-6/,,y <br />Term One Year _ <br />Invesbr alive S ee S 500 in-state bion-refundab <br />Investia-ative Fee 52,500 out-of-state to maximum of S 10.000 <br />DATA PRIVACY NOTICE, The data you supply on this foam will be used to assess yo� qualifications for thelicensc. You are not legally required to <br />provide this data, bill we will not be able to grant the license witboot it If a license is ynarsed, the data you have supplied will consBtnte a public record <br />and copies may be issued to anyone requesling thew, 'fhe required deal allows as to distinguish you from other applicants; to identify you in our license <br />files; to verify that you are the person who applied fbr the license; to contact you if any additional information is required; to determine whether you <br />meet any nuuiunnm age requirements; and to detennure if any conviction yon may have on record might affect year suitability as alicense-holder Yoru <br />residence address and telephone number will he considered pflu <br />public data unless you request s information tobelawate and provide an alfemalire <br />address and telephone number (ace below), <br />Signature -� <br />I request thal: my residence : dd <br />Address _4 �5 <br />Phone <br />j� _ 1 <br />_!-1 e-_.-woY <br />(First, middle and last nave <br />for and in behalf of PIA <br />Pleasesign booty to indicate that You have read this notice: <br />are as follows: <br />as_.:EJT1'1fPf i'... -z ,era'..Lim;-6r .._�fl4Per <br />(nrndivid i� owner, ofticer w immer) <br />hereby submit this application for an On -Sale Intoxicating Liquor & Wine License for: <br />for the sale of intoxicating liquor in accordance with the provisions of Minnesota Statutes, Chapter 340 and the St. <br />Anthony CityC;2dx,, Chapter 1000. _ <br />I <br />tronyw� g// y� and ending S.._...�-�C)L""'—.____. For: 9'fJ�_aep'3m�rIS�.Y_.'ACt-�df_LV1'ti"..SYYi_ <br />Y (Signatuf.�e of Person Making Applicaaon (igame Of Individual, Partnership, Corporation or Association)�t��� <br />State of. mneso'di } <br />County ofHemrepiar } <br />Jih•ear 0/ <br />Subscribed, acknowledged and sworn to before are thisJ-1-- day ofLV;L_7'l <br />In support of said application and in accordance with the requirements as set forth in said Chapters, there is <br />attached hereto, in duplicate, all applicable parts and personal information forms, liability insurance policy, <br />workers compensation policy, bond, license and investigative fees. <br />