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Attachment A
<br />-p,
<br />OF pul
<br />Minnesota Department of Public Safety
<br />ALC'0110L AND GAMBLING ENFORCEMENT DIVISION
<br />33.
<br />444 Cedar St., Suite 13 3, S�t, Paul) 1VN 55, 101 -51
<br />(651) 201-7507 FAX (651)297-5259 TTY(651)282-6555
<br />WVW-DPS.STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No ficeMe, will' be app . roved -6r. released until the �$2,0 R�tailer ID -Car'dfee is received
<br />Workers compensation insurance company, Name Id ap !j i c a U V- V1 cc CIO. Policy # I 3� 1i
<br />Licensee's A4N Sales and
<br />Use! Tax,)OD # U j ILA 3 Fpp-
<br />yj To, applyfor a MN sales and use tax ID #, call (651) 296-6181
<br />Licensee's Federal Tax, W,
<br />If a c�oirpioratio,n, an officer shall execute this application If a partnershi p, a
<br />Licensee Name (Individual) Corporation, Partnership,, LLB ) Social Security #
<br />�6FILLOC� �j
<br />License Location, (Street Address & Block No.) License Period
<br />city
<br />Kosevii Ut
<br />Name of Store Manager
<br />r1%
<br />P ]!cauon.
<br />MUM
<br />Trade Name or DBA
<br />�aiylbouj Roods 4?9'Ool 0'
<br />Applicant's Uome Phone #
<br />Zip Code
<br />DOB (hidividual Applicant)
<br />- - ramcc K aut -L, vyao I I.P.5f - q ?? 1- rd - - of 01
<br />Ifai corporation or LLC state name, date. of birth, Social Security- # address, title, and shares. held by each officer. If a partnership, state
<br />names, address and date off rth of each partner. pbasf See ocvlx,:�i
<br />Partner Officer (F'i t, nWdle, last) DOB I SS# ITitle. Shares I Address, City, State, Zip Code
<br />I Partner Officer (First, rniddle; last)
<br />I Partner Officer (First, rriiddle, last)
<br />DOB SS# Title
<br />DOB SS# 5—tic
<br />Shares I Address, City, State, Zip Code
<br />Shares I Address, City, State, Zip Code
<br />Partner Officer (First, n�iiddle, last) I DOB I SS # I itle i Shares I Address, City, State, Zip Code
<br />6. State whether any person other than applicants bas any right, title or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, gt , vc name and details.
<br />7'. Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />® Yes C3 No If yes, give name and address of establishment. PUOSP
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