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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 />me Address <br />1411 w l( c�_'j / o -I V] <br />*Attach Additional List of Necessary <br /># of Shares Owned Date of Birth <br />in 6 0l`ZK - <br />(10) The name and address of each director of the applicant is as follows: <br />Name <br />Address <br />Date of Birth <br />i'? Wi Sbd� <br />✓17({ <br />1/V I (SIA <br />114A <br />g ig3 <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 />Addre s <br />Title <br />Date of Birth <br />>.4 <br />/� &Lwa- <br />® <br />C <br />'12 --3 <br />►21C1.A1 I <br />% GVNzv1KlSu <br />J D -Jo - <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,(Prin <br />Signature: <br />DRIM <br />I%, <br />i <br />To Be Completed By Office: <br />Date R )quest Received <br />By . C$2,000.00 On -Sale Fee Received aYes / ❑ No <br />(Staff Member) $200.00 Sunday On -Sale Fee Received Yes / ❑ No <br />Look for us on the World Wide Web at gemlakemn.org <br />