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2014_0106_CCpacket
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2014_0106_CCpacket
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Attachment A <br />Minnesota Department of Pubiic Safety <br />ALCOHQL AND GAMBLiNG ENFORCEMENT DIVf510N <br />444 Cedar Street, 5uite 222, St. Rau�, MN 55101 <br />(651) 201-7531 TDD {651) 28�-6555 <br />FAX (651) 297-5259 <br />APPLICATION FQR BREW PUB OFF SALE <br />_____INTOXICATING LIQUOR LICENSE <br />Workers Comp, Ins, Co. Liberty Mutual Fire Insurance Corrtpany Policy Number WC2-Z91-456850-023 <br />Minnesata Tax ID Number 3806136 Federal Tax 1D Number 26-2456488 <br />�� a w�N��ou�n ur �i� state narrte, aate or pirtn, Socia� Security Number address, title, and share hefd by each officer. Ifa partnership, <br />state names, address and date of birth of each partner. <br />Partner OfFicer (First, middle, last� DOB 55# Title Shares Business address <br />Robert James Doran CEO/President 0 1685 Hampton Course 5t Charles IL� <br />Partner Officer (First, midd <br />James Gerhard Gilbertson <br />Partner Officer (First, midd <br />(First, <br />� � �� <br />1. If a carporation, date of incorporation <br />, amounC paid in capital <br />and give purpose of corporation <br />55# <br />SS# <br />SS# <br />1� � ,� <br />CFO/SEC �0 <br />Business address <br />3709 Dunbar Knoll Broakfyn Park M� <br />Business address <br />, s4ate inwrparate in <br />If a Subsidiary of any other corporation, so state <br />authorized to do business in the state of Minnesota? C3Yes � No <br />ness aaaress <br />. If incorpprated under the laws of another state, is corporation <br />2. Describe premises to which license applies; su�h as (first floor, second flaor, basement, etc.j or ifentire building, so state. <br />3. Is establishment locatec! near any state university, state haspitai, training school, reformatory or prison? �Yes �1 No <br />ifyes state approximate distance. <br />4. Name and address of building owner: <br />Has owner of building any co�nection, directfy or indirectly, with applicant? QYes � No <br />5. Is applicant or any of t�e associates in this applitation, a member of the governing body of the municipality in w�ich this license is to <br />be issued? {�Yes [j No If yes, in what capacity? <br />6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license <br />is applied and if so, gi�e name and details. <br />7. Ha�e applicants any interest whatso�er, directly or indirectly, in any other liquor establishment in the state of Minneso#a? <br />[jYes (� Na If yes, give name and address of establishment. <br />
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