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<br />Minnesota Department of Public Safety
<br />A1.COHOL AND GAMBLIIYG ENFORCEMEhT bIVISION
<br />444 Cedar St., Suite E33, St. Pau�, MN SSIQ]-5133
<br />(651) 20]-7507 FAX (65l)297-5259 TTY(651)2$2-6555
<br />W W W,DPS.STA"I'E..MN.[JS
<br />Attachment A
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<br />APPLICATION �'OR OFF SALE INTOXICATING LIQUOR LICENSE
<br />]Vo license wili be a roved or released until fhe �20 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name _� f' Po[icy #�
<br />I.iCenSCe'S M� sa�CS ei1C1 U5e �ax I� # To applyjor a MN sales and use 1ax ID fl, ca!! (651j 296-d181
<br />Licensee's Federal Tax ID # •
<br />If a cor oration; an of�eer shall exect�te tt��s a ��caE�on If a artnershi , a artner shall execute this a lication.
<br />Licensee Name (Individt�al orporation Partnership, LLC) 5ocial Securitv # 1"rade Name or DBA
<br />' !Yt � 6�� Gc%i rr �e � ��ri �s ,�ti . '. . . _ - - . - - ��' �/�i G�in � �- � �`r� � fs
<br />License Location {SCreet Address Block Na.) License Period Applicant's Home Phone ##
<br />� I�� l�1-��l.�j�`�.GL�' �7/C' � From /%��—� 9 T o�o �3�� 0/ � _
<br />C��y Co ry State Zip Cade
<br />R45� Ur /l� �5 M/lJ .�S//,� '
<br />Name of 5tore Manager $usiness Phone Number DOB (Individual Applicant)
<br />T �3 .� No I+.en� -� �-
<br />If a corporation or LLC slale name, datc of birth, Social Security # address, titie, and shares heid by each officer. If a�artnership, sEate
<br />names, address and date of b'rrth af each partner.
<br />P3riner Offcer (Firsc, middle, last) DO� . SS# T�+�P • 5i�ares Ad�ress ''"�- ".! V- • �
<br />_ _ ; , d ° � - -�_ . ,. ..
<br />Part�er Officer (First, middle, ta , DOB S5�! irlP„ � 5hares � ^ -"-es- ^'` "� "' � ' '
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<br />� Partner pFficer (Firs[, middle, 1
<br />� Pariner Officer (Pirst, middie, last)
<br />�DO$ SS# itle
<br />DO� S5� itle
<br />Shares I Address, Ciry, 5tate, Zip Code
<br />Shares I Address, City, Sta1e, Zip Code
<br />If a corpe*�+�^^ �'^�° �r �~--rporation � � ` � , state incor orated in •
<br />P , amount paid in
<br />capital _ f a�nh����ar.. ,�Y �� oCher corporaiion, so state and give purpose of
<br />corporation _ .]f incorporated under the la�vs of another state, is corporaiian
<br />authorized to do business in the sf�fe of Minnesota? C Yes � No
<br />De�cr�h� nrwrnicac fn Whtr.h license applies; such as (first floor, second floor, basemeni; ete.) or if emire building, so state.
<br />Is esfablishment located near any state university, state hospital, training school; �-eformatory or prison? �Yes �Io if yes stace
<br />approximate distance.
<br />4. Name and address of building o��ner: � h f`r I' � Sf �� L L�
<br />� W - !� 6 � .�.fi. � o � R %� -��� N SS�a
<br />Has o��ner o ui �ng any connection, �rect y or in irecily, w�t applicant. C Yes No
<br />5. Is applicant or any of the associates in this application, a member of the governing body af the municipa]iry in �i�hich this ]icense is
<br />to be issuec�? [=i Yes �10 If yes; in ���hat capaciry?
<br />State whether any person pther than applicanCs h s any right, title or interest in the furniture, fixiaires or equipment ior which license
<br />is applied aad if so, give name and details.
<br />�ve applicants an�� interest whatsoever, direcYly or indirectiv, in any �ther ]iquor estabfishmen in the state af Minnesota?
<br />Yes u No [f yes, give name and address of establishment. S� ���
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