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10-02-'08 10:16 FROM-D'Amlco Account g 6123174229 T-856 P002/009 F-171 <br />Attachment A <br />0*0&- . . . - , . <br />Minnesota Department �o�f Public Safety VI 4E <br />1 4j <br />ALCOHOL AND GAMBLING ENFOROEMJENT DIVISIO � N <br />444 Ccdar St,, Suite 133, St. Pauli MN 55�1,01-5133 <br />(651) 201-7507 PAX (651) 297-5259 TTY (651) 282-6555 <br />WWW.DPS.STATEMMUS <br />APPLICATION' FOR NTT /CITY OIL -SALE WINE LICENSE <br />(Not to rxcccd 141/6 of alcohol by volunie) <br />EVERY QUE-STIONM.UST BE ANSWERED. If a Corporation, an officer shall oxecutc this application. If a partnership, LL C, a partinct <br />shalll execute this applicatiOn. r2 <br />Worker's compensation insurance company. Namc Policy # <br />LICENSEE'S MNS ALE S, & USE TAX" ID # —To apply for W Sales Tax ciall (651) 296-6181 <br />LICENSEES FEDEPALTAX ID <br />Applicants Name (Ausiness, Plannershipi, Corporation) Trade. Name or DBA <br />Business Addrrnss 8usiness Phone ADiDlicants H <br />16 orne Ph on r, <br />T:> <br />Is this application <br />Mew or a O'Tra nsfeu <br />County, State <br />If a transfer, give name of 'former owner Licensc pertod <br />From <br />If a, cog?2ration, give name,, fitle,_addrr.ss iand' date of birth of each oflicer, If <br />Partnicr/Officer Name and title <br />IL) <br />Partner/Officer N'ame and Title <br />PartnerlOfficer Name and Title <br />Partrict/Officer Name and Title <br />Zip C'Ode <br />To <br />nor ship, LLUrve name, address and date Of birth Of edCh ptwiner. <br />Address Social Security # D 6-B- <br />Address Social Security # DOB <br />Aiddress <br />Address <br />CORPORATION'S <br />Date 0 incorporivion, State of incorporation Certificate Number <br />�5� Wma E= %vmNV) CD <br />If a subsidiiary iof another =Wratiion,give name mid address otparent corpt4iron <br />Social Security # <br />WI corporation authorized 1,0 do business in Minn%otA? <br />—Yes 0 No <br />BUILDING AND RESTA - URA,NT 'I <br />C)'Wnorsad'dew, 1-7 - <br />nbe: thic premises to. be lictnsibd W6 <br />J-0 <br />Ct V%�JT <br />the restAbrant is in conjunction with anoither bu,gints,s (resort etc,). describe business <br />NO LICENSE WILL BE APP D OR RELEASED UNTIL THE; 0 RkTAILER ID CAPJ3 FEIE IS ]RECEIVED 13Y AGED <br />K <br />a <br />