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Miesota Department of'Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br />444 Cedar St.
<br />Suite 133,,St. Paul, MN 55101-5133
<br />(651) 201-7507 FAX (651)297-5259 TTY(651)282-6l555
<br />WWW.DPS.S`TATE..MN.US
<br />APPLICA TIT NFOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />Worke�rs compensationm'surance company. Policy
<br />Licensee's MN Sales and Use Tuir F" -4 Y;g qpp�yfor a AI N sales and use tax ID call (651) 296-6181
<br />Licensee's Federall"Tax ID #
<br />!_coy porstion.an otheer stiau execute this Apefication Ifs- rtnersNp.,a r,tner shall execute this a )Hcation.
<br />Liomsee Nwne (Individual, Corporation, Partnership, LLQ Social Security # rr-radeName or DBA plp
<br />,,tl LL EntJ ;J . .- 11 w- W. 4
<br />license Location (Street Address & Block No.) License Period Applicant's Home Phone 4
<br />."') 0 ) 'l 'rt A4 . - . .0 m .0 i ... I �
<br />city County State zip code
<br />Nam c of Store Manager B-asiness Phono'Nurnber
<br />DOB (Individual. plicant )
<br />If a corporation or LL(.' state name, date of birth, Soleffif Slecurity address, tittle, and shares held by each onices. it, a p., Jate
<br />names, address and date of birth of each piai-itneir.
<br />..........
<br />Partner Officer (First, middle, last) DOB
<br />I I SS# Shares Address, City, State, Zip Code
<br />Partner Officer (First, middle, last) DOB SSW Title Shares Address, City, State, Zip Code
<br />Partner Officer (First, middle, last) DOB SS# Title Shares Address, City, State, Zip Code
<br />Partner Officer (First, middle, last) DOB SS# Title Shares Address, City, State, Zip Code
<br />If a corporation, date of incorporation state incorporated in amount paid in
<br />capital If a subsidiary of any other corporation, so state, and give purpose of
<br />corporation 0 If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? 0 Yes !] No
<br />1 Describe premises to which license applies; such as (first floor, second floor, basemcnt, etc.) or if entire building, so state,
<br />3, is establishment located near any state university, state hospital, training school, reformat ory or prison? f"Iyes )(No If yes state
<br />approximate distance,
<br />4. Name and address of building owner:
<br />Has ow, 'of" building any connection, direcitly or indirectly,, w'fffi applicant? 777YP ml WNo
<br />5. Is app[icant or any of the associates in this application, a member of the governing body of the municipality in which this license is
<br />to be issued'? 1-I Yes L] No If yes, in what -capacity?
<br />16. State whether any person other than applicants has any right, title or interest in the fumiture, fixtures or equipment for which license
<br />is applied and ifs, give name and details.
<br />7. le appliewits-any interest whatsoever, dire�ctly or indirectly, in any other 1i uor establishment in the state of Minnrsota?
<br />"I
<br />es i No If yes, give name and address of establishment.
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