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not be effective until a permit shall be issued under the laws of the United States in <br />case such permit is required under said laws; and that the applicant will keep said <br />license posted in a conspicuous place in said premises; and, <br />(9) The name and address of each shareholder of the applicant and the number of <br />shares owned by each is as follows; <br />LName Address # of Shares Owned Date of Birth <br />ohrkPl anc3 703 S_ Riviera 100%s 11/19/48 <br />; WBL,MN <br />*Attach Additional List of Necessary <br />(10) The name and address of each director of the applicant is as follows: <br />Nam_ e I Address Date of Birth <br />(11) The name and address of each officer of the applicant and the office held by each is <br />as follows: <br />Name <br />Address <br />Title <br />Date of Birth <br />oh►, M. i'r, hAd <br />19a S.Riu;era Dr' ld_� L <br />Pl-eSide h <br />// 4 <br />Dr' 1 <br />�203 A?idjrN Dr' <br />/' P �s��nt <br />e� a�_ 5j <br />/- <br />T hh <br />cirlen like land <br />k 903 S• E1v1e'ru Dr' WBL <br />ul rl <br />03_�0� <br />(12) The undersigned certifies that all information provided in this application is true and <br />accurate and that he/she is properly credentialed to make this application. <br />Name (Print) I Title (Pri <br />John M. Birkeland Presid( <br />Signajure: r, j1 ,1 , , <br />To Be Completed B Office: <br />Date R ff quest Received <br />/jx <br />By . V�_ — <br />(Staff Member) <br />Date <br />12/10/"12 <br />$2,000.00 On -Sale Fee Received , Yes / ❑ No <br />$200.00 Sunday On -Sale Fee Received '[] Yes / ❑ No <br />Look for us on the World Wide Web at gemlakemn.org <br />