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<br />Minnesota Deparhnent of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DNISION
<br />444 Cedar St., Suite 222, St. Paul, MN 55101-5133
<br />(651) 201-7507 FAX (651)297-5259 TTY(651)282-6555
<br />W WW.DPS.STATE..MN.US
<br />Attachment A
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<br />APPLICATION F'OR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the $20 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name ) f- j�% Policy #-�J �'I'��� �
<br />Licensee's MN Sales and Use Tax ID # �,y9 9 �>% To apply for a MN sales and use rax ID #, call (651) 296-6181
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<br />Licensee's Federal Tax ID # C�/ - c9 ��� (� ���
<br />If a cor oration, an officer shall execute this a lication If a artnershi , a artner shall execute this a lication.
<br />Licensee Name (Individual, Corporation, Partnership, LLC) Social Security # Trade Name or DBA
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<br />License Location (Street Address &�
<br />City
<br />Name of Store Manager
<br />No.)
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<br />License Period
<br />From To
<br />County
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<br />Business Phone Number
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<br />Applic s Home Phone #
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<br />State Zip Code
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<br />DOB (Individual Applicant)
<br />If a 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 of birth of each partner. S� � �; -� �,, •!
<br />Partner Officer (First, middle, last) DOB SS# Title Shares Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />Partner Officer (First, middle, last)
<br />DOB SS#
<br />DOB SS#
<br />Shares � Address, City, State, Zip Code
<br />Shares � Address, City, State, Zip Code
<br />Partner Officer (First, middle, last) DOB SS# itle Shares Address, City, State, Zip Code
<br />1. If a corporation, date of incoiporation _�`` �= 7� �`l _, state incorporated in /��. '�/7 �'/.P�i �� , amount paid in
<br />capital �j . If a subsidiary of any other corporation, so state St�.ti's ���u5 and give purpose of
<br />cotporation �c�...l e�e���k�.� `�' . If incorporated under the ws of another state, is corporation
<br />authorized to do business in the state of Minnesota? ❑ Yes ❑ No
<br />2. Describe premises to which lic/e/j]se applies;�O$ll/ch as(first floor, se�
<br />�T : /� ( - i •�'/ ..7 .p _ �. _-_ e C
<br />3. Is establishment located near any state university, state hospital, training
<br />approximate distance.
<br />r, basement, etc.) or if entire building, so state�.
<br />ltq�'E-ec� P�ri'�on oF .�('..ur �la�
<br />�ool, rQ eformatory or prison? �Yes �No If yes state
<br />4. Name and address ofbuilding owner: ��'^���} R�� f���- ��°`�-p � S""� � S�
<br />2oi /V1a�� -Sf. L.a �as.s
<br />Has owner of building any connection, directly or indirectly, with applicant? � Yes o
<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 is
<br />to be issued? ❑ Yes �No If yes, in what capacity?
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<br />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, give name and details. .�(/�
<br />Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of M'nnesota?
<br />�Yes ❑ No If yes, give name and address of establishment. �`c ��' i i'�t c-( �r� /•` �' �9 �� �� C�"% '�' i%
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