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Minnesota Department of Public Safety dmtrt,
<br /> LIQUOR CONTROL DIVISION
<br /> 444 Cedar St., Suite 100 1- St. Paul. MN 55 10 1 - 2 156
<br /> (6 12)296 6430 'I'I 12)282-6555
<br /> APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br /> No license ,y ill be apprm ed or released until the 520 Retailer ID Card fee is received by MN Liquor. Control.
<br /> Worker ,compe7usationiusuranceeompam . Name 1 , T. F.�. T. ✓s. �/ -'OV;� Policy# �U /�JC[urJ
<br /> LICENSEE "S WA'S & USE TAX II) # 3 �3 / y� 1'o apph for sales tax #, call 296 -06181 or 1- 800 -657 -3777
<br /> If a co oration, an offcer shall executethis a lication Ifa artnershi , a artner shall execute this a lication.
<br /> Liceusee Name (ludr<idual, Corporation, Partnership) Trade Name cr UBA
<br /> License Location (.Slreet Address & Block No.) Lice .� Period Applicant's Home 1'Loue
<br /> 70"13 J ✓r r,, S U, From 7 %,' to / %S' 6 12 - 77.7 - 0SS )
<br /> C'it_` County State Zip Code
<br /> CEy J�2�7t.L�
<br /> Name of S(orc Managcr Business Phone Number DOB (Individual Applicant)
<br /> ��n,y�r96F� &Z -VU -6W /2
<br /> corporation, state name, date ofbirth, address, title, and shares held by each officer, If partnership, state
<br /> ies, address and date of birth of each partner.
<br /> Partner Oflicer!tir:l- middle. last) DOB Title Shares Address, City,State. Zip Code Ix
<br /> 1A/v2 ihfs 13r�� Jfrts lor.�; N
<br /> Patner Offlcn 0=u st. middle. last) DOB I Shares Address, City, Slate, Zip Code
<br /> Punier ChTicer r'irst. middle. last) DOB T tle Address, City, State, Zip Code
<br /> Partner Dfficcr (First. middle, las1T' DOB Title Shares Addre s City- .State, Zip Code
<br /> 1. If a corporation, date of incorporation .S - 6 - yS' , state incorporated in I N. , mnount paid in
<br /> capital y 1-7X DO . If a subsidiary of an) other corporation, so state and gi 'c purpose of
<br /> corporation 4IZ4 If incorporated under the laws of another state, is corporation
<br /> authoracd to do business in the slate of Minnesota? ❑ Yes yNo
<br /> 2. Describe premises to which license aplicsi such as (fir floor, second floor, basement, etc.) or if entire building, so state.
<br /> �tRST F Oo� ' J �eCY+o.> G/-` S7F /p M,r LL
<br /> 3. 1, eslaMli' :ueut located near an) state university, state hospital, training school, reformatory or prison? G Yes XNo Ifyes
<br /> state appro\uuatc distance -
<br /> 4. Nmne and address of building o«mcr: 1oNn/ Mn (I + - L ( /'� +,�/ S i ��.r/''(/�U [ t ,H ✓, J So3 3
<br /> f las owuer of building auy connection, direc or w&recth with applicant? ' O Yes V No
<br /> 5. Is applicant or any of the associates in this applicatiou, a =nber of the governing body of tie municipality in whicb this begun:
<br /> is to he :7 Yes XNO If) es. in what capacin'?
<br /> Stale 101aicr sty person other Wan applicauts bas am right, title or intterer in the furniture, futures or e ipr ent for wbich
<br /> license i applied and if so, give name and delails. /-J� C J fS CIF & ',/r SS I�/2Y .S..�ySlr f e[, fi,✓ /'f -LlJ
<br /> 7. Have applicants any interest whatsoever, directly or indirectly, in any other liquor "ablislunuent in the 5 ale of Mmaesota? 113 ✓ `Z•
<br /> ❑YesXNo U}' e,. gr% ename and address ofeslablis }uucot.
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