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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 />lutoxicatin i�it nor & Wte <br />Sunder <br />Tel <br />Tivestieatit�e Pee <br />Invest- ipattve_Fee <br />APPLICATION FOR ON -SALE <br />INTOXICATING LIQUOR & WINE LICENSE <br />000 <br />4_200 <br />One Year <br />R%500 in-state non-refu_ndabie) <br />1500 out-of-state, to maximum gf $1_0,000 <br />--- -- <br />Receipt t __ <br />License'#.' <br />MN Tax 1I) <br />DATA PRIVACY NOTICE: 'Ii c data you supply on this farm will Uc usut to assess Your qualifications for the license. You arc not legally required to <br />provide this data, but we will not be able to {yant the license without it. if a Geensc is gra lred, the data you have supplincl will coustimte a public rccmd <br />and copies Only be issued to mryone ruluesung them. lire required data allows Its to disc aguish you from other applicants; to identry you in our liceuse <br />Glu; to verify that you rule the person who applied for an license, to contact you if rely additional information is raluired; to durneinc whether you <br />meet coy rtiznulnun age tequtrwneots; and to deximine if any conviction you may have on record might affect your suitability as a liccnsoholder. Your <br />residence address and telephone n rumor will be considered public dam unless you request Uus information to be private and provide an alenionve <br />address and telephone mmilxr (see below). <br />Please sign below to indicate that you have read this notice: <br />signature <br />1 smelt that any rceldnme address and ic.epiione n.mlber be considluod private data. My elucrnativc address and tetcphone. nueioer arc es foimve: <br />AddleSs .._._---- <br />Phone . Phone <br />GUY PL=T R>ON_.._ _ as oE-- 'LR .-_--- <br />(Y r5 niddie and last tame ofr c mak ng ap piano•) .. (Individial owner, oincor or panncr) <br />ST. ANII MY RESTAURANT GROUP, INC. <br />for and in behalf of---— <br />Qudividunl/Partnership/Coq>o�ation) <br />hereby submit this application for an Oa -Sale Intoxicating Liquor & Wine License for; <br />located at ST. AN-1-1-IONY PKWY/1 WY 88/KENZIE TERRACE <br />—------(S:rcct Address and/or Plat and Parcel Numbc') `---- <br />f'or the sale of intoxicating liquor in accordance with the provisions of Minnesota Statutes, Chapter 340 and the St, <br />Anthony City Code, Chapter 1000. <br />commencing----__-.— ---J_---_..--and ending------,---------_—,_ <br />For: <br />(Sigaamre of Person Making Application (Naunc of Isdrvidual, Pa,^metskep, Corporation or Associar'on) <br />Sate ofMinncsota ) <br />County ofl{¢uicpin ) <br />sabsslrei, ackuewlelged cold swore to before Inc this _ day <br />By: <br />In support of said application and fit 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 />