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OF
<br />Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br />444 Cedar St., Suite 222, St. Paul, MN 55101-5133
<br />(651) 201-7507 FAX (651)297-5259 TTY(651)282-6555
<br />W W W.DPS.STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the $20 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name Policy #
<br />Licensee's MN Sales and Use Tax ID # 519 7Q 5 To apply for a MNsales and use tax ID #, call (651) 296-6181
<br />Licensee's Federal Tax ID # e5 7 7 !K j
<br />If a corporation, an officer shall execute this application If a partnership, a partner shall execute this application.
<br />Licensee Name (Individual, Corporation, Partnership, LLC)
<br />Social Security # Trade Name or DBAUu
<br />i
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<br />Licen Loc on (Street Address & Block No.)
<br />License Period
<br />Appl cant's Home Phone #
<br />From To
<br />Zip Code
<br />City
<br />County
<br />State
<br />IOIJAS rl
<br />A
<br />Name of Store Manager
<br />Business Phone Number
<br />DOB (Individual Applicant)
<br />l- �-e
<br />03-W-'76
<br />If a corporation or LLC state name, date of birth, Social Security # address, title, and shares held by each officer. If a partnership, state
<br />names, address and date of birth of each partner.
<br />Partner Officer (First, middle, last)
<br />DOB SS# Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1 �Il�d�
<br />71�v1 r �rn1`
<br />Shares
<br />G i
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1. If a cor oration, date of incorporation 5 �-a ! ,state incorporated in ���,5 D t a ,amount paid in
<br />capital If a su}�sidiary of any other corporation, so state and give purpose of
<br />corporation r inv, . If incorporated under the laws of another state, is corporation
<br />authorized to do hisiness In the state of Minnesota? ❑ Yes XNo
<br />2. D cribe emIs s to which lice se applies; such as (first floor, second floor, basement, etc.) or if entire building, so state.
<br />3. Is establishment locat4 near any state university, state hospital, training school, reformatory or prison? ❑Yes Po If yes state
<br />approximate distance.
<br />4. Name and address of building owner: I k41 6A4 n-ca- " W i�Y
<br />�Wq ` ��y� 1) J A6 � 56 %
<br />building 'd ,
<br />Has owner oan connection,direc o indirectly, ❑ Y es JO No
<br />5. Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license is
<br />to be issued? ❑ Yes Po If yes, in what capacity?
<br />6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, give name and details. rAn� OAP - (',Qhta o c aUl,r(,hut,
<br />7. Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />❑ Yes O.No If yes, give name and address of establishment.
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