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M <br />City of St. Anthony <br />3301 Silver Lake Road <br />St. Anthony, MN 55432 <br />(612) 789-8881 <br />Fee: <br />IntoxicathntLiguor Wine <br />Sunday <br />Tenn <br />hr zS—ggatve Fec <br />Investi¢ative 11,ee <br />APPLICATION FOR ON -SALE <br />Il`iTOKWATTNG LIQUOR & WINE LICENSE <br />� 200 <br />S 200 <br />One Year <br />% .500u1-statenon-refundable <br />S2500 out -of --state to maximum o f S10 000 <br />Receipt <br />License # <br />MN Tax A7 it <br />axrA Flzl ACY NOTICE: The data you supply on this form will be used to assess your qualifications for fire lioense. You are not legally re<luired In <br />provide this data, but we will not be able to grant the license without it. If a license is grated, the data you Have supplied will constitute a public record <br />arrd copies may be issued to anyone requesting them. 'Die required data allows as to distinguish you flout other applicants; to identify you in our license <br />Hles; to verify that you are the person who applied for the license; to contact you if smy additional information is mclaimil; to dctetmino whether you <br />meet any minimum age requirements; and to determine if any conviction you may have on record uright affect your suitability as a license -holder. Your <br />residence address and telephone number will be considered public data unless you request this information to be private and provide an alternative <br />address and telephono nuvnber (see below). <br />f hi bdtle Mexican GrLll yr qur.auu, �, <br />p Plc tgu below to indicate that you buveread flus nohee: <br />Signature by Zl its LLC Mana er -- ----- <br />1 regn t Ilrat my reside:me address gird telephone number be consideixxi pnvatr, daft My flttemahve address and bdoldrone number area. fellows: <br />Address 1543 Wazee St., Sit e.1200, Denver, CO 80202 <br />as LLC ilnna;er ..._------__--- <br />(]first, middle andlast nantc ofpmsonmal.mn application) (Individual owner, ofEw r of partner) <br />forandinbelialfof Chipotle Mexican Grill of Colorado, LLC <br />Qndividuai/Putuership/Corporation) <br />hereby submit this application for an On -Sale Intoxicating Liquor & Wine License for: <br />Chipolte Mexi.cam,';Gr:ill <br />located at <br />]O1.-_ th Ave. NE Suite 128 St._Anthony Village, MN <br />(Street Address and/or Plat and Parcel Number) <br />for the sale of nntox3cating liquor in accordance with the provisions of Minnesota Statutes, Chapter 340 alit the St. <br />Anthony City Code, Chapter 1000. <br />commencing _ Jmie 15 _ 2005 _and ending..._-_— <br />/5,fi✓t�t� <br />For: Chi.potl_e Mexican Grill. of Colorado , LLC <br />(Signah of Person -Makin Application (Nameofindividual,Partnership, Cogori&norAssociadon) <br />,State of AixtxesoCz Gly ca <br />CountyofN=.gpai <br />o vtv (<a, <br />Subscribed, acknowledged midr o° e�.�or+�i t�lfiS, 'o day of _ ( <br />By: <br />u <br />In support of said applica ud°in aoc6tt,5lapye with the requirements as set forth Chapters, there is <br />attached hereto, in duplicate, 1 'lic ffelArts and personal information forms, liability insurance policy, <br />workers cdmpensatiou polio, boud, � aegse, aria lltvestigative fees. <br />