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°' Minnesota Depamnent of Public Safety . .,
<br /> LIQUOR CONTROL DIVISION
<br /> 190 5th St. E.. Suite 105, St. Paul, MN 55101
<br /> ti... (612)296-6430 TTY(612)282-6555
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<br /> APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br /> No license will be approved or re d until the S20 Retaer ID Card fee is receh ed by Mai Liquor Control.
<br /> Workers compensation insurance company. Name W, �V iq_Su k" �c& Pofie)j 7 :3 3 7
<br /> LICENSEE'S SALES &USE TAB{ID 70 To apply for sales tux #,call 296-06181 or 1-800-657-3777
<br /> If a corporation, an officer shall execute this application If a partnership, a partner shall execute this application.
<br /> Licensee Name (Individual, Corporation,Partnership) Trade Name or DBA
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<br /> License Location(Street Address ,&Block No.) License Period Applicant's Home Phone
<br /> From T o f `
<br /> City County State Zip Code
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<br /> J5e-- CA J X�v 3
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<br /> Name of Store Manager Business Phone Number DOB (Individual Applicant)
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<br /> If a corporation, state name, date of birth, address, title, and shares held by each officer. If a partnership, state
<br /> names, address and date of birth of each partner.
<br /> Partner deer(First middle,last) Title S a r e s Address,:ity,State:,Zip Code
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<br /> 1 9, r es /1733 51wve�r I Q V
<br /> Partner Officer (First, middle, last) Title Shares Address, City. State. Zip Code
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<br /> Partner Officer(First, middle, last) DC Title Shares Address, City, State, Zip Code
<br /> Partner Officer (First, middle, last) DOB Title Shares Address, City, State, Zip Code
<br /> 1. if a corporation, date of incorporation 3— t 17 , state incorporated in I(A` eS4 amount paid in
<br /> capital /0 , If a subsidiary of any other corporation,so state and g&purpose of
<br /> corporation If incorporated under the laws of another state, is corporation
<br /> authorized to do business in the state of Minnesota? Yes C1 No
<br /> 2 Describe premises to which license applies; such as Must floor, second floor,basement, etc.) or if entire building, so state.
<br /> 3 Is establishment located near any state university, state hospital, training school, reformatory or prison? n Yes %No If yes
<br /> state approximate distance.
<br /> 4 Name and address of bufl&mg owner: A4 b IV� 7e a e S
<br /> Has owner of building an connection, directly or indirectly, with applicant? 0 Yes JiWo
<br /> 5 Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license
<br /> is to be issued? n Yes "Io If yes, in what capacity?
<br /> 6. State whether any person other than applicants has an, 'ght�title or interest in the furniture, fixtures or equipment for which
<br /> license is applied and if so,give name and details. _
<br /> 7 Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br /> C Yes 00 If yes, give name and address of establishment.
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