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<br />� Attachment A
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<br />1�111\ ,
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<br />tvtinnes ota �e.��arfluw7t of Public 5afc3y ,� ' �j
<br />ALCOiiOi. AND GAhIBLlivG EI�RoRC�i4I��vTi}iV[SrUN � .��.
<br />4d4 CcGor 5�., St�.iEc i33, $i. I'���f, MN SSiOt•Sf33 s��
<br />(G51)20l-7507f�i1X.(6i1)��7-$259'il'Y(b51?282-6555 ������� ,
<br />W R'N':Df'S.S'E`A'I'i:'..MM335
<br />ApPLtCATIOiv fipr� O�'fi SAt,� rNTOYICATtH� t,I UOR �.icEivs�
<br />f�o litrnsa SYili ba� rovecl or rnfe�sed u.ntEl the 520 Retalicr lD GrU fee js. rce frcd
<br />1Varkars Cu1lt�eissatiaij i�lsvrailce cvm�atlp..i�la�l�g . rZ� e�. pofrcy H ,�,
<br />LtttnscE'SMNSAItSArt(IUSC`CAtID� I/ Y roR�vrrfo�n��f�raa„�r��s�„�rou�rrresr�i
<br />Liccn:t�'s �'t�t�al Ta� ID p _. � 3�
<br />Yf A cor ereelo�. au ofG.rer si�a1! ezrcate tttis �r licntiwi lta �ariuei�sh� , p ar�ner 6h�1! execuEC thfs n 1Ec�tlaa,
<br />Liccnscc tV�tma (lrs�ividual: Car�mrhtion, Pi�rnicrship, LLC`) tinrinl C��rn,r;�;• a �p�IC i�lnmrOr [3RA
<br />�/C� �` ��JUF L.tC�, � L� L 1�1�.���'L � �� L�.0 d-
<br />Litzncc i,ocation (Sare�t qJ�resy &[31nc1; Na.� L'iCCnst �'�rrpd Ann�iCnni's Nnma Phont
<br />�7� � ,L�x�� n .� ��.�
<br />City �
<br />Naine oE S[arC lvlana�cr
<br />Frn �s1 7b
<br />C ��Y S�atc
<br />�i� w�-�il.�Y, �� �
<br />�3i+sincss Phouv N nber
<br />'/_ip Cnde
<br />�0� ((t�dividua� Appiicanl)
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<br />iC� coYpanlE3ou bc Li,C �IRtc noi�se, dafe of I�irfh, Sa�tai 3cruYily tl ad�l��ss, litle, Hntl stiarer I�elci b�� cqtlti ofjiccr. Tf p. pqltiieTShJp� slate
<br />��a�i.sea, ndttrest ued d�1td of A[�•�t� of wlch pnrtnrr.
<br />��� • R � � �� � �J vji V � ii V
<br />Pa�tn�rUFFircr •its�,midclic,lnst) D�A 55# I'iitc
<br />Paihiec Q1liccr (['irs�. �nidcifo: I�st} U0�3 SS#
<br />Partner OtTiccr {riist, nuad[c; lasi} � llOD � SSN
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<br />C 7i�!`..Ai I I
<br />Shores � Adc}rtiss, Cit�. StaTC� 2i Cag de , ^
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<br />Shnrcz � Ad�ress, Gity, S1a�e;2ipCode
<br />Shnres I J�J�f��y, �ilr. SCate, ZipCo(ie
<br />Eti1 COtpOrafi0f4. d51C 0( isi�tf�6Yalinn , s{¢CC i�i�orpanlCd in . qtllpuAl pPiQ iFt
<br />ce�ilail . II"n subsidinry ol"anyothrr ccufxsroliun. sa slatc . anctgire purposa oF
<br />�orpora.liai� . i!'incorpurastd uq�f�r t}�� �pws ofbrlpEl�cr S1afE, is c.arparalion
<br />:rulhori[ed la do busiites.i in lhe sla4E of Minnesata7 " Yes :. No
<br />Drsrri �+ �ise.s to �vlsich liccnse anplias; such as {�',rs.t �I�or, sccnnd tinor,: basertuni, cir,j pr 1F enRirC bui2dii�g, 90 3�SIC.
<br />Isas�abfishsncrtt loc��rd ucar any 5inro un�vcrsily, sh�tu hvspital, Irainiisg schuol,rcFonnnlniy ur pr�son? i:Y�g : o fycs ��ale
<br />�pprv�iinart dis[nnu.
<br />an�{ a�ldr�s§ i�('
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<br />nus awner or auria�tig nny t�i�ric�t�oA. a��cetlr ar ��� �r..ct �, w11 i qpp .icanf. :": eS �
<br />Is b�plieaF2t pi nny dP'tha :t c'tolcs rn khis ep�liCntion; � is�ern6ct 4 f 1ht govcrning hndy
<br />So bw i5cued:F : Ye� ': jJa f��:5_ iri tivhnt iopticii±f?
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<br />ii3 �rhich thiy I�ce3�se fs �
<br />$�otc �+•licShcr atty persv�i other lhais bppEirB�ifs ling n�tiy ri �11, l7[EC OT ililGTiSI IR jlk: I'i[f)IIl14fC, iIX10►CS 07 C�VE})�liCri� lOf tvllsC�j �j«�y� �
<br />is applicd and it sa, gir� nairtc nnd clefoifs. /UO�iJ�
<br />}lnrc ap is auy� inlrntisl�v€iaisoevor. dir�rlly or in�irectly, in ���y osl�er liqisnr estyb�isl�nrcni in �t�r s��� pPMfflttesofa?
<br />'i Ycs . No� f��es, givc �tiauu nn�1 �ddics� nFrstal>>+3hni�ui,
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