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<br />MinnellOla Department of Public Safety
<br />ALCOHOL AND GAMBllNG ENFORCEMENT DIVISION
<br />444 Cedar SI., Suite 133, SI. Paul, MN 55101.5133
<br />(651) ZOI-75(J7FAX (651)297-5259 TIY(651)282-6555
<br />WWWDPS.STATE..MN.US
<br />
<br />APPLICATION FOR OFF SALE INTOXICATING UQUOR UCENSE
<br />No lIco_ will be . or nle...... nntD the 520 RflaUor ID Card reelo ncelvod
<br />Worl<er. compensation insurance company. Name Policy # 0 z. 1 'f 2.. 7 2.. 0 I
<br />Licensee', MN SalOl andUseTuIDII ~t~~tf TDapplyfor.MN,al.,..dwet",lD~. ,al/(65/)2'J6.618/
<br />~.Fed.raITu ID# 'is - 0'5
<br />If a co ration an ofticor ,han eiecute thlt. U""lioo If a artnenhl a
<br />Li see Name (Individual, Corporation, Partnership, LLC) Social Security #
<br />St.u
<br />
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<br />Licen", Location (Street Addreas &..Block No.)
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<br />
<br />
<br />rtner ,haU eiecute thla a
<br />Trade Name or DBA
<br />
<br />Ucation.
<br />
<br />,
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<br />(I<-
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<br />
<br />1
<br />City
<br />
<br />
<br />Stote
<br />V
<br />
<br />Zip Code
<br />6505~
<br />
<br />From
<br />
<br />To
<br />
<br />County
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<br />OOB (Individual Applicant)
<br />
<br />\D 4..j ....
<br />If. corporation or LLC...te nam.. date of birth, Sociol Security # addr<u, tld<, aDd "'.un hold by'- om<<r. rr a portnonhip, state
<br />lUIIleo, add.... and date ofblrlh of.- partn....
<br />om= iFi"", . die, la3l) DOB
<br />,J 10 2.1 '1
<br />
<br />DOB
<br />
<br />Name of Store ManBger
<br />
<br />Busim:ss Phone Number
<br />
<br />Portner Officer (Fir.l~ middle, la.t)
<br />
<br />
<br />Add,..., City, SIllIe, Zip Code
<br />SIS"llsfscj./14 0"'-';
<br />
<br />Addres., City, Stole, Zip Code
<br />
<br />
<br />Pllrtner Officer (Firs~ middle, laat)
<br />
<br />Shares Address. City, Stole, Zip Code
<br />
<br />OOB
<br />
<br />SS#
<br />
<br />Partner Officer (First, middle, la.t)
<br />
<br />Shares Addre.a, City, Stote, Zip Code
<br />
<br />OOB
<br />
<br />SS#
<br />
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<br />
<br />Ifa corporation, date ofincorporalion 1 I-vz./ Of? , state incorporated in K N , amount paid in
<br />ca.pital . If 8. subsi~f any other COrpoJ'8-tiOfl~ 30 state and give purpose of
<br />corporation . If inoorporalcd under the laws ofllIlother mate, is corpomtion
<br />authorized to do business in the Htate ofM:innesots? U Yes UNo
<br />
<br />2.
<br />
<br />. ch licemc: applic,sj., such WI (first floor, second Ooor, basement, etc.) or ifl::ntire building.. so state.
<br /><i-- ~v -R ,,;'.1 x
<br />Is establishment located near any ,tate unive , ,tate bo.pitRI, !mining school, refonnatory or prison? UYea ll(l No Ifye. state
<br />approximate distance.
<br />
<br />])cser'
<br />
<br />
<br />3.
<br />
<br />4.
<br />
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<br />("")1"":1 c,;/-,U rll'''10 i0/J ~~o~B
<br />
<br />5.
<br />
<br />Name and lI<ldreaa of . dill!! owner. .5 l 5 I
<br />~ 0s0-
<br />
<br />o row Ing any connectIon, lree y or In re y, WI app tcant e'S.J Q
<br />I. applicant or any of the associate. in this application, a member of the 8"veming body of the municipality in whieb this License ia
<br />to be i..ued? J Ye. ~o If yea, in what capaeity?
<br />
<br />6.
<br />
<br />State whether any peroon other than applicanta has any right, title or interest in the: furniture, fixturea or equipment for which license
<br />is applied and jf so, give name and details. ------Al.JJ .
<br />
<br />7.
<br />
<br />Have applicanto any interestwhBlllOever, directJy or indircclly, in any other liquor eatablishmcnt in the state ofMinnesota7
<br />J Yea ){NoIfyes, give name and ad"""'a of eatabliahment.
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