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�,Eµ °""&t Minnesota Departmcni of Pu6ti� 5afcry � �TK€.sr,,T
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<br />x s ALCOHOL AND GAMBLIRG GNFQRCEMEIVT DIVISIO� �°' �^,� �,
<br />494 Cedar St., 5uite 133, St, Paul, MN 55101-5133 ��,�`�4` �:z�
<br />s„����• (6S1} 201-7507 FAX {651} 297-5259 TTX (65i} 282-6555 ��,����
<br />3i, ..��T .
<br />°.°..,..•` WWW.�PS.STATE.iV13�z.U.S i• �
<br />APPLICATION FOR COUIVTYICITY ON-SAL.E W.TN.� LICENSE
<br />(T*Iot to exceed i4% of alcohol by volume)
<br />E'1'�RY QUESTiO1N MUST BE ANSWERED. If a corpo3-ation, an officer shall execute this ap�lication. [f a partnership, LLC, a partner
<br />shall ex�cut�e this appiicati�n.
<br />Workers compensation insurance company. I`'z^r° �''r't.' � �' � °'�° ���u���'c�licy # � �� �� 7 ��
<br />LICErSEE'S Mt�' SALES & USE TAX llj #t _To a�ply for M1�' Sales Tax # call (651) 29G-b 181
<br />LICEI�SEE'S FEDERAL TAX ID #
<br />Applicants ?�ame (IIusiness, Partnership, Corporation) 7'rade �lame or DBA
<br />� v J��O �� � �...`� ���
<br />Business Address Busincss Phone '
<br />f � � �i C ��t-L� �� G �--� (�� ) (�3� -� 13 �
<br />City ` County State Zip Code
<br />�O`J�V t� l � �.�c��� �� �� �,�
<br />Is this application [f a transfer, �ive name of former owner License period
<br />� Nerv or a n TransCer From To
<br />IF a co oration, ivc namc, titic, address and da[c of birtli of cach officcr. IFa ar[ncrshi ,.LLC, �ivc namc, adda�css and da[c of birtB pf cach aRncr.
<br />Par�nerlQfFicer Name and tidc Add �ss "° -`-' ^ " D�08 �
<br />� ' - -
<br />Pa��tner!(}frr.rr �.ra�.,� �,,,� T;.ie � � � e,�,�,-P��
<br />� . •
<br />Partnerl0fficer 7�amP an� 'i';+tP n .+.�.� _
<br />_ � - . , _v_ �,
<br />PartnedOfficerltlarne and 7'itle
<br />�
<br />Address
<br />CORPORATIONS
<br />Da(e oi inc rpprati n $tate oF incorporatiori � Certiftcatc h'umber
<br />I f f� Z e� U(A 1� � �l+n +� SO
<br />IFa subsidiary o.f anosher corporaiion, give name and address of pa�enl corporation
<br />Name ofbuilding owner t
<br />�.�,� �. �.s F� � 1
<br />Are Propersy Taxes de.linquent?
<br />C1 Yes �No
<br />Hou�'S food �vil] be availa�le���
<br />I � /a-�[ �- i � ��'i
<br />Describe Ihe prem:ises lo Ue licensed
<br />` cA.t't� C r ^�.0
<br />- ' Cnr;a3 co�.._:�. � � I�OB �
<br />I .
<br />�
<br />c����i cP,,.,.:�.; �+ p�1 - g
<br />� � �.
<br />.�,
<br />I Social 5ecurity # � DOS'
<br />s orporation authori�ed to do business in Minncsota?
<br />, '� Yes ❑ No
<br />B�iLnz�'G AND R�STAURANT
<br />Ow�cr's a dr s
<br />. 1-��1��� �� �. t �� w.�,� �� �C;
<br />Has tlie building owne ny cc�nnecFt.i��onn,', direcs ar indireca,
<br />with thc applica»t? �l Ye5 yi�0
<br />r
<br />�'o. oFpeople restauranS employs %`p, of rnprths per year restaurant
<br />� 5 wil� he open k Z,
<br />i 'L_.Z�-� 1(' e:`7�c
<br />0
<br />[fthe res�aurant is in conjuiution with another business (resoit.etc.), desarihe business
<br />�_� e.�-v� ��s
<br />Rest;�urant sealing capaciry
<br />4d
<br />e O'ZZ\ �. 'ZG�. t
<br />W ill food scrvicc 6c ihe principlc busincss?
<br />�Yes �� 1�'0
<br />�
<br />N� LIC�EN�S� WI�,L B� APFROVED OR RGLEAS�p UNT1L THE $2� �2E'i'AIL�R [D CARA FEE �CS RECETVED BY AGED
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