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Minnesota Department of Public Safety <br />` Alcohol and Gambling Enforcement Division <br />`� `�; 444 Cedar Street, Suite 222, St. Paul, MN 55101 <br />651-201-7500 Fax 651-297-5259 TTY 651-282-6555 <br />APPLICATION FOR COUNTY/CITY ON-SALE WINE LICENSE <br />Aicohol & Gambling Enforcement <br />(Not to exceed 14% of alcohol by volume) <br />Print Form <br />EVERY QUf5T10iV MUST BE ANSWERE�. If a corporation, an officer shall execute this application. If a partnership, LLC, a partner shall <br />execute this application. To apply for MN sales Tax # call 651-296-6181 <br />Workers compensation insurance company name _� � ,�� � �- °e<<`a.���� ;" � �, �'������.:r�'� policy Number �� r �� �`�� � �j ,� �; �_ <br />Licensee's MN sales and Use Tax ID # �_�__� ���� Licensee's Federal Tax ID # <br />Applicants Name (Business, Partnerships, Corporation Trade Name or DBA <br />' %'r�'i�s - /`'/ - l. L� � �: iCNI�� % �l <br />Business Address Business Phone <br />/ 7// /�'�cyG �%2��i �Sl �7 �7�i7,� <br />City <br />Cou nty <br />-� <br />� �.�'�-!'� : <br />Applican <br />� <br />State <br />Home Phone <br />p Code <br />�� C�r S� �'/GC�- /��/d 1 /�-'iiti'` . ,.. <br />Is this application If a transfer, give name of former owner License Period <br />�'New or a� Transfer From To <br />If a corporation, give name, title, address and date of birth of each officer. If a partnership, LLC, give name, address and date of birth of each partner. <br />Partner/Officer Name and title �.�:��� <br />�%��% � � 7s=! ' � .-� <br />Partner/Offi er Name and title <br />Partner/Officer Name and title <br />Partner/Officer Name and title <br />Add ress <br />Address <br />DOB SSN � <br />DOB SSN <br />CORPORATIONS <br />Date of incorporation State of incorporation Certificate Number Is corporation authorized to do business in <br />I'%/�yj J-�-C I� l�o�v:��� y"c>� �� j% j�y3�L!l `7 G�i�%� � 6 Minnesota? �°Yes � No <br />If a subsidiary of another corporation, give name and address of parent corporation <br />BUILDING AND RESTAURANT <br />Name of building owner Owner's address �.y-�3� <br />��' f�' � �o, �� ��„„ l-ir— -' r3%�%v'�'!:'�f3�% �f�.ieslt,�. ��- � L"���=- eL.�t f�G.� ?,UP.,.Eri � Mn•� <br />Are property t xes elinquent Has the building owner any connection, direct Restaurant seating capacity Hours food will be available <br />� Yes [y�'No or indirect with the applicant? � Yes [�"No �' /�-,t.� _ �'� �,�y <br />Number of restaurant employees Number of months per year restaurant is open Will food service be the principal business? <br />� j� [�'Yes ❑ No <br />Describe the premi�es to be licensed <br />���af �-� �7\ I �!�,l��r`�.� ��L��l i� ��1�-f�1..:� t t�9 � C�-� E-`�`�+�' <br />Ifthe restaurant is in conjunction with another business (resort etc.), describe business <br />?7 .� �; t� i s'.ai, J 9' s^� , r/1- �_'r ?—i :"'_." :1 r'�r, �.. f°r.�, <br />NO LICENSE WILL BE APPROVED OR RELEASED UNTIL TWE 520 RETAILER ID CARD �EE IS RECEIVED BY AGED <br />� Yes [�]'No Has the applicant or associates been granted an on-sale malt liquor (3.2) and/or a"set-up" <br />license in conjunction with this wine license? <br />� Yes �No Is the applicant or any of the associates in this application a member of the county board or the city council, which <br />will issue this license? If yes, in what capacity? <br />(if the applicant is the spouse of a member of the governing body, or another family relationship exists, the member <br />shall not vote on this application. <br />� Yes �No During the past license year, has a summons been issued under the liquor civil liability (Dram Shop)(M.S. 340A.802). If <br />Yes, attach copy of the summons. <br />� Yes �o Has applicant, partners, officers or employees ever had any liquor law violations in Minnesota or elsewhere. If so, give <br />names, dates, violations and final outcome details: <br />Page 1 of 2 <br />