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City of St. Anthony <br />3301 ilver Lake Road <br />St. At thony, MN 55432 <br />(612);789-8881 <br />Fee: <br />APPLICATION FOR ON -SALE <br />KICATING LIQUOR & WINE LICENSE <br />Receipt # <br />License <br />MN Tax ID # <br />._. "I r rvv r li,n: 1110 awa you suppl on this form will be used to assess your qualifications for die license. You are not legally required to <br />provid this data, but we will not be able to grunt t ie license witliout it. If a license is granted, the data you bave supplied will constitute a public record <br />and, ies may be issued to anyone requesting thn n. 7110 required data allows us to distinguish you from other applicants; to identify you in our license <br />files; t verify dist you are dte person who applied for die license; to contact you if any additional information is required; to detemune whedler you <br />melt ajry mmunn r ale requirements; and to dere nine if any conviction you may have on record might affect your suitability as a nicer se -holder. Your <br />M cc address and tc lephone, number will be cl nsidered public data unless you request this information to be private and provide an alternative <br />addr0s and telephone number (see below). <br />Plea n below to <br />that my residence address and telephone kumber be <br />I, �o��r L. �JrVZs%' <br />(Fi1st, middle and last name ofperson mak <br />for aid in behalf <br />I <br />hereby submit this application for an <br />d at <br />local 2-/ Z <br />—�—��KGN zf c <br />for tl e sale of intoxicating liquor in t <br />Antii ny City Code, Chapter 1000. <br />State ifMinnesota } <br />Courof Hennepin } § <br />Subsclibcd, acknowledged and sworn to <br />Lt s0port of said application and i. <br />atta lied hereto, in duplicate, all ap <br />wor ers compensation policy, bond <br />you have read this notice: <br />as follows: <br />as o/`Fi Ce -/Z_ <br />(individual owner, officer or partner) <br />/"j C_ <br />Intoxicating Liquor & Wine License for: <br />i -Le %N.t' ✓,_ <br />of restaurant or hotel) <br />Sr. A-�r•/o•�•y <br />st y '18 <br />with the provisions of Minnesota Statutes, Chapter 340 and the St. <br />and ending <br />For: <br />(Name of Individual, partnership, Corporation or Association) <br />this _2 day of 7 <br />accordance with the requirements as set forth in said Chapters, there is <br />icable parts and personal information forms, liability insurance policy, <br />icense and investigative fees. <br />.ted► <br />- pEANNE F. KOlo <br />Notary Public <br />t <br />Minnesota <br />(` Oili�ilttkt Errn^^J^^^sm 3t, 2010 <br />