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<br />r ~) Minnesola Department of J'ublic Safcty _,j1'll~
<br /> LIQUOR CONTROL DNISION ~i~'4
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<br /> 444 Cedar $I., Suite /00 L. St. Paul. MN 55/01-2156 ~.~'
<br /> , . (612)296-6430 TTY(612)282-6555 .~,.:< ',_li::/
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<br /> APPLlCA TION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br /> No license will be appn)\'ed or released until the SZO Retailer ID Card fee i. recti,'ed bJ MN U'Iuor ControL
<br /> Workers compclI~alioo insurance company. Name Policy#
<br /> LICENSEE'S SALES & USE TAX If) # rd. 9J3-0;~>'{6~ To apply for salcstax #, call296-06181 Or 1-800-657-3777
<br /> ~ M370'7'5"5" If a DartnershiD, a Dartner shall execute this aDDlication.
<br /> If a cornoration, an officer shall execute this aDDlicatioD
<br /> Licensee Name (Individual, Corporatiou. Partnership) Trade N amc or DBA
<br /> CN/t4J .tNt, (."'.e n-fef^V, I Ie tlft''''''-;;
<br /> License Location (Street Address & Block No.) !.icen"" Period TO/~/o~ Applicant's Ilome I'llOue
<br /> 7()q 3 ;)(I'tI, five S'. From -t) /01 67'-330.-46- &'0
<br /> City Couoty State Zip Code
<br /> {e11 relZvu...U .A- h-c kq lid !Ii ;;56:'; g-
<br /> Name of ~lore Manag"" Business PhOlle Nnmber DOB (Individual Applicant)
<br /> ;VJ ult A.-f. / J: W"H.Nl""~ i:; 1- ,/.:2{-hI7</ 7- .2-tr- 7z-
<br /> a corporation, state name, date of birth, address, title, and shares held by each officer. If a partnership, state
<br /> nes, address and date of birth of each Dartner.
<br />=,'artner OOiccT (Fir,;!. 1I1iddle.la.<t) DOll Title Shares Address, City, Sl~ Zip Code
<br />/l1l dl./UI W4/rnav I '11'1-' G '"'"" 'i Ave
<br />T 1-Zf'-U. i1" kd4/<, /-fA) ~:r/U
<br /> P8I1ner Officer (FirS!. middle. last) DOD Title Shares Addre..", City, Slate, Zip Cooe
<br /> Partner Officer (FirS!. middle.laS!) DOB Tille Shares Address, City, Slate, Zip Code
<br /> Partner Officer (first, middle, last) DOB Tille Shares Address, City, Slale, Zip Code
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<br /> I. If a COrporatiOll, date of incorporation . state incorporated in )1'lYIhe-fc+<i , amount paid in
<br /> capital , If a subsidl,dy ;;rany other corporation. SO state and give PUJ1lOsc of
<br /> corporation . If incorporated under the laws of another state, is corporation
<br /> authorized to do business in the state of Minnesota? 0 Yes 0 No
<br /> 2. Describe premises to which license applies; such as (fITst floor, second floor, basement. etc.) or if entire building, SO state.
<br /> r/"", Ft.CdR .
<br /> 3. Is eslablishmeullocated near any state university, stale hospital,lraining school, reformato!)' or prison? DYes ltNo Ifyes
<br /> state approximate distance.
<br /> 4. N8IlIeandaddressof~uildingowncr: JUhn MrtJJII 77.'j :20'"' At;; N. L...v 4ku MJJ ,,,SoH?
<br /> {,"/- (;.6' - J'f-10 lIas owner of building any connection.dircclly or indircctJ;y,wilh applicant? DYes DNo
<br /> 5. Is applicant or any of the associates in this application, a member of the governing body ofthc municipali!)' in which this license
<br /> is to be issued? [j Yes l!I No If yes. in what capacity?
<br /> State wbether any person olher than applicants has any right, title or iutereot in the furniture, frourcs or eCjl1ipmCllt for which
<br />- license is applied and if so, give name and details.
<br /> 7. Hille applicants any interest whatsoever, dircctJ;y or indirectly, in any olher liquor eslablishment in the slate of Minnesota?
<br /> DYes /, No If yes. gn'e uame and address of establishment.
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