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<br />Attachment B
<br />Minnesota bepartment of Public Safety
<br />ALCOH�L AND GAMBYIINC ENFORCEMENT I)TVISION
<br />444 Cedar St., 5uite 133, St: Pa�l, MN 55101-Si 33
<br />(651) ZQI-75D7 FAX (65 ])297-5259 i"I'1'{651)282-6555
<br />W1�VW:DPS'_STATE..IVII�T.LJS
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<br />APPLTCA7'�ON FOR OFF SAI.� TIVTOXICATIN� �TQUOR LICEiVSE
<br />No Iicense ivilI be-a raved or reIeased uintil the $2D Retailer ID Card'fee is recefved
<br />Workers compensation insnrance company. Narne i C S tiYl.��t cC C�. Policy #� V,1C` I( 5 3� ��
<br />Licensee's MN Sales aud Use �'ax ID #��� l n ��3 _ To apply for a MNsales und use raxlD t7, cnfl (b5I)196618I
<br />Licensce's k'e[feral Tax ID#,�it r1 -�/ � 3 G�f n( n
<br />If a car nrafion an otficer sball execute this a lication If a artners�i , a artner shall execaie this a licatian.
<br />Licensee Name (3ndividual, Corporatian, Partrkership, LLCj Sociat Security # Trade Name ar DBA
<br />��F,�-�-cc� Lv;scov�st�n wlv+ �r�t,n��w Foa�is ��goa (t+ vov}
<br />Licensa F.acation (Street Address & Biock t�fo.) License Period Applicant's I3eme Plione #f
<br />1dOl lN• C�� �v�i-�vY 1lCI'PVt FromQ1�f08 To Fa-�3i'o� �%�'.33i- SC�C?
<br />C�ty County 5tate Zip Code
<br />I�o�e v i l Le �a vv� �e y m N 5-S ! r 3
<br />Name of Stare 1Vlanager
<br />�1'L.�� 1( Qu�' z_ I�tGc.v�
<br />Business �hone IVumber � D�B (In.dividual P.pplicant)
<br />(�sr - �l Q�- dga� �rl��
<br />If a cor�arafian or LI,C sYate name, date of birth, Social Security # address, title, and. shares held by each officer. If a partnership, state
<br />names, address and daEe otbirth of each partner. �( a�? tp .CPP Q�CI C�L[ raJ
<br />OFf cer (FirsE,
<br />Partner Officer (First, midd�e, lasE)
<br />Partner OfScer (F'irst, middle, last)
<br />DOB SS#
<br />]]OB 5S#
<br />DOB SS#
<br />Shares
<br />Zip Code
<br />Shares � Address, City, State, Zip Code
<br />Shares � Address, C'sty, State, Zip Code
<br />Partner Offieer (First, middle, �ast) i]OB SS# iEle Shares Address, City, State, Zip Code
<br />1. If a corpo �ation, date of incorporafion � r J 9 � , staYe incozporated in W i sC�� �`d ►'� , amount paid in
<br />capital • 5L7 r . If a subsidiary of any other corporarion; so state � ' C'. and give purpose of
<br />corparation . Tf incorporated under the laws o another state, is corporation
<br />autE�orize� to do bus'vi s in the state of innesota? C?'�es fl No
<br />2.
<br />to which license applies; such. as (first floor, sacond floor, basement, etc:) or if entire building, sa sta[e.
<br />�5 Dc�ce a d s ae�� � , e
<br />3, Is establishment located near any sta#e university, state hospital, training school, reformaEory or prison? �Yes CHGo If yes state
<br />approximat.e disiance.
<br />4. Natr3e and address of building owner; � � Y� Ca� '�
<br />�Ol �1flLltin SfY �,�-- �vi tc $� La vn . w S`��20 r
<br />as owner o ui �ng any connection, Erect y or m reet y, wrt app �cant. � Yes o
<br />5. Is apptican.t or any of the asg ociates in this application, a mernber of the governing body of the municipality in which this license is
<br />to be issued? ❑ Yes l�'l�a If �es, in what capacity?
<br />G.
<br />i
<br />5tate whether any person other than appficants h any right, title ar interest in the fumitvre, fixtures or eGuipment for which license
<br />is applied and if so, gi�e name and details.
<br />Haue applicants any interest whatsoe�er, directiy ar indirectly, in any other liquor esta6lishrrient in the state af Minnesota?
<br />p Yes � No �f. yes, give name a�id address of establishment. � Q fp CP.2 Qi1��lGh�td _. _
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