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<br />- - --- -Minnesota De�aarkment of Public Safety �;�, �� - ��� �
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<br />-.; Aicoho! and Gambling Enforcement Divisron _- - -
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<br />444 Cedar Street, 5uite 222, St, Paul, MN 55� 0 -- -— --- -- I
<br />�� �` 651-201-7500 Fax 651-297-5259 TTY 6S 1-282-6555
<br />- �' ` APPLICATION FOR COUNTYICITY ON-SALE W1NE LICENSE
<br />A1�oh�ri�i� C�mblriig l�nfarcemenf'. (Not to exceed 14% of alcohol by vdlume)
<br />EVERY QUESTlQN MUST BE ANSiNER�D. lf a corporation, an officer shall execute ihis app.lication. If a partnership, LLC, a partner shall
<br />execute this applicatian. To apply for MN saies Tax # call 651-296-6181 j
<br />Workers compensation insurance company name � �',�'% �t�C �dL�(Tir�it�'°��cy ��mber ��� "c�.�c/'c1��J / ;
<br />, � � �- �� .� � Licensee's Federal Tax ID # �r�--� i
<br />Licensee s MN sales and Use Tax ID # �
<br />Applicants Name (Business, Parknerships, Corporation Trade Name or DBA ;
<br />L�-1 �.�' z. L, G° L., (�" %!�'.s' � ;
<br />Bus,rin^�ess Address Business Phone Applicant's Hame Phone �
<br />v� �� 7...5� �/�" ,��.' i�t r- � � � � � � �`"l ��,.�Z C} "" """ !
<br />City( Caunty State Zip Code ;
<br />/`� nJ�' � t�°1 ��-� -� r/ i
<br />Is thi pplication If a transfer, give name af former awner License Period j
<br />�New or a[] Transfer From To Z ;
<br />If a corporat3on, give name, title, address and date of b(rth of each officer. If a partnership, LLC, g3we name, address and daCe of birth of each partner. i
<br />Partner/Officer Name and title Address ,.�. ,_., .r r,r. DOB SSN �
<br />"'f A . '
<br />� iil% � �U11i�11• �„_ _. _ _ - . � � I
<br />Partner/Officer Name and title Address DOB SSN ;
<br />DOB SSN
<br />Partner/Officer Name and tifile Address �
<br />I
<br />PartnerlOff+cer Name and title Address DOB 55N
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<br />CORPORATIONS ;
<br />Date of incarparation State af incorparation Certiflcate Number Is corporation au#horized to do business in
<br />�Z�� � � r � � ,� Minnesota? Q`Yes ❑ No
<br />If a subsidiary af another corporation, give name and add ess af parent corporat or►
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<br />BUILDING AND RESTAURANT
<br />Name of building owner Owner's address ��/'/ j ;
<br />y r� � C ...2.�"�.,5� i/�" �z'-d,.� l��✓�, /'P�5`Z"r�lL� �� �
<br />� � f �..•l..- ^" '
<br />Are property taxes delinq ent H s the building owner an connection, direct Restaurant sea� g capacity Hours food wiil be availabl� ;
<br />licant? Yes o � ��� '� � � j
<br />� Yes [�io or indirect with the app 0 [�
<br />Number of restaurant employees IVumber af mo�s per year restaurant is apen Will food service be the principal business? �
<br />[�Yes C'] No j
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<br />Describe the premises to be licensed '
<br />� % r,� � � � e�it� ,
<br />If the restaurant is in conjunction with another business (resart etc.}, describe business �
<br />d� '
<br />NO LiC�NSE W�LL BE APPR4VEp €3R RELERSED UNTIL 7HE S20 RETAILER ID GARD FEE IS R@CEIICED BY AGED �
<br />[� Yes No Has the applicant or associates been granted an on-sale maft liquor (3.2) and/or a"set-up" �
<br />iicense in canjunction with this wine license? ;
<br />licant or an of the associates in this application a member ofthe county board or the city council, which i
<br />�j Yes � o Is the app Y
<br />wilt issue this license? If yes, in what capacity? �
<br />(if the applicant is t�e spouse of a member of the governing body, or anath�r family reiationship exists, the member �
<br />shall not vote on this application.
<br />[] Yes �o During the past license year, has a summans been issued under the liquar civil liability (Dram Shop)(M.5.340A.802}. If '
<br />Yes, attach copy of the summons. �
<br />[� Yes [i1�No Has applicant, partners, ofFicgrs or employees ever had any liquor law violations in Minnesota or elsewhere. If so, give '
<br />names, dates, violations and final outcome details.
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