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<br />ApP'LICA"Ci.qiV fiOlt O�`fi SA�.� �NTO�CICAi1lYG L_ 1QU0� ��r
<br />�io licenso tiviil bo ApRrov
<br />1Vorkers c�it��ps�uation i��sur�Etce companp, ida�ne
<br />Li�ensee's MN 5aRes Artd Use Tax Ib � lI" �
<br />Lic;encl�'S FZdCrsl i'e� 1D p
<br />Yf A cor ur��io� ��} �fficer sliail ex�c�ce tttis m
<br />l.icenscu N�tma (!nd'tvidt�af. Cospsrr�tion, Pnrn�nrshi
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<br />Name of Stotc Ml�nag4i
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<br />Policy � �R.r,J ,.,
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<br />Yin cor�ontEiau ur L#.0 afaEO nm�ic, dalc of ifSrtl�, Soc�pl5ct�rily Il nddrtes, lifle, �nel s6aras I�Plcl b�• earh oflicer. lf R�ARfICCdili�� 61AIE
<br />��amsa, ndtiruc und dfit� of hfrtt� of e�1CR �sartntr.
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<br />Shnres � Addrtss, Cit�, Statc, 2� d �
<br />Shf�z�# `Address, Gity. S�ale, Zi� Cn�#e
<br />Shnres �,�dslrec9, CiiY, Sfa[e, Zip COde
<br />I. 11'A COF(i4fal10R, dalo of incqrgoralinn _ , s�u[C incnrpninted in . Rinpunl pAid in
<br />ce�itad . 11"a subsidinry of nny oiher u�r�wroliun. sn s�a1c ancl �ive pu�soso o F
<br />�arpora�io:� . il';ncorp�rased �nJu �hc laws ofa��ull�cr slarc, is corpuralion
<br />:�ulhari[eA ta do business in Ihe slate of Minnesola? '� Yr4 :. No
<br />2. Descri �miset lo tvlfieh lica[ase a��►lios; suCh as pirs� (�oor, secnnd tinor, bnseat�eni, ele,? ar iF enlire building, so statc,
<br />]. Escslnbl�shment Enc�tcd �uar any smca onivc�sify, stutu hnspital, lraining school, rcian�ntory ur prison? .,Y�S � o Fycs staie
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<br />�i�4 Ow�c� 0� tsqi�pfll� akly LOniICCtIpi4. nartctly or i[ldtirc:c[U�, w111i epp�icant. :�: es : � '
<br />�3 A�p1iC8iN Ar pnr o�f�he n eiates in Ihis ap}�!i[ntion, �,z�e�nhcr �f !hc go�erning bocly o! i ic nuuticipe�ity ii� tirhich thi9 iiceose ig
<br />So b� iscued'! : Yry ': plo ,�:s. in �vhat cu�eil�!�
<br />StoEC �t4kclhcr any persa�i o�hvr thn» epplicnn(s I�ns noy ti ltit, �itEe or in�cT�s� in th,; l'�naiwrc, fixlures or cqui�men� far whiclt Iicuuc
<br />is applicd and et ao, giro na�nc �nc� detuf [S, /�%il1 � .
<br />}�pvc ap IS any infrrtssl �rhalsaevar, d'u�ectly or inJizec�I��, in �ny o�l�srliyi�nr estab�isltimrn; in n�r s��c oPME�1�Yesolo?
<br />'1 Ycs , Na� Fyes, girc nanu ait�l adcli�cs� ufes�•rbli9hn�eu�.
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