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<br />Minnesota Department of Public Safety z, y,�"`'; �
<br />� �.:'., �� .,._.; ;:
<br />t � ALCOHOL AND GAMBLING �NFORC�MENT DIVISION ��`���`�,., � �
<br />1J Sf��OpM�NNEa�P 444 Cedar St., Suite 222, St. Paul, MN 55101-5133 ```��?;x��s+�,:''�
<br />'- -- (651) 201-7507 FAX (651)297-5259 TTY(651)282-6555
<br />W W W.DPS, STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the$20 Retailer ID Card fee is received
<br />Wcrkers compensation insurance company. Name����!"� �i�-� �"jt3'lL,,,r -Ct/'1� �fJ� Policy # � (,p�,,�(� `� (� "jR-��
<br />Li�ensee's MN Sales and Use Tax ID # I� To apply for a MNsales and use tax ID#, call (651) 296-6181
<br />Licensee's Federal Tax ID #�7 �-� � 67 �� �
<br />If a cor oration, an officer shall execute this a lication If a artnershi , a artner shall execute this a 1
<br />Licensee Name (Individual, Corporation, Partnership L) Social Security # Trade Name or DBA
<br />�'r.css� `-���.ca. ccse � i qi �� �,� , �.�.c. lYl Gn� GvTn e� �- �S ;
<br />License Location (Street Address & Block No.)
<br />/l'�% Lc�.�/�e.n-�-°� �v� 19-v��, !n/��s��-
<br />City
<br />�U�-evi ll �-
<br />License Period
<br />Fromq �� t � To
<br />county
<br />��
<br />r�}�S
<br />Applicant's Home Phone #
<br />'�tate Zip Code
<br />rl�n1 .� s �t.�
<br />Na�ne.of Store Manager Business Pho��Number DOB (Individual Analicantl
<br />�ta' � �- �7�C' � �Gc h lA'V� � �'�lw'���.� �,�
<br />If a corporation or LLC state n me, date of birth, Social Security # address, title, and shares held by eacl� officer.
<br />names, address and date of birth of each partner. -�
<br />a partnership, state
<br />Pa tner Officer (First, mid'dle, last , DOB SS# Title Shares Address, City, State, Zip Code � ^
<br />�ur�f l�u,� 1��s ll �
<br />Par(�tner Officer (/First, middle, last)///��q�i p i�nR ��S# fTitle I CharP.c � a�l�,•P�� �;n, crarP �;,, r�,�P
<br />\' � 1% n e 1/VI./:L�% V
<br />Partner
<br />Partner Officer (First, middle, last)
<br />2,
<br />� bOB � SS#
<br />DOB SS#
<br />Shares I Address, City, State, Zip Coc�P
<br />Shares � Address, City, State, Zip Code
<br />If a corpg,rati n, date f in�corporation ����'�`�� , state incorporated in f��V , amount paid in
<br />capital � � � , p . If a subsidiaiy of any other corporation, so state • and give purpose of
<br />corporation °�-----•-� . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Mimiesota? ❑ Yes ❑ No �—�/�j�
<br />Describe pre ises to which 1'cense applies; such as (first floo , s cond floor basement, etc.) or if entire building, so state.
<br />�i �n°���S�c�� � � � �'Ot� s�t = ��' �h �� � s�- ��l r�u� �� fi�1r�p n�r� l l - 0�1 e �e� � /
<br />Is establishment located near any state university, state hospital, training school, reformatory or prison? ❑Yes ❑ No If yes state
<br />approximate distance. !1 L� 1°V11 L� "� i�� iS CO IMGt d�l °�- ��' lllf'�I t� C��I'� l�odll lllP.�'f�`� ���
<br />�- Gf niv� '� F �o �-�► vves�-� � �- i o�s N� '� �- �-r'�'c�.�h'u �,s � ' fi ��n� r�i�
<br />Name and address of building owner: (� � � `� �- �- � ' � �r✓iC%%i/�� �' °'(
<br />�s�b l e `� �, • r3�-�� �l �� �8�� �ar�. �
<br />Has owner of buil ing any connection, directly or indire tly, with applicant? Yes
<br />Is applicant or any of the associates in this application, a member of the governing bo
<br />to be issued? ❑ Yes �No If yes, in what capacity?
<br />�v
<br />�
<br />of the municipality in which this license is
<br />State whether any person other than applicants h�s�any right, title or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, give name and details. �/r.�
<br />Have ap 1'cants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />❑ Yes �10 If yes, give name and address of establishment.
<br />:�
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