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<br />Mi��nesota DepartmeE�t of Public Safety
<br />ALCOHOL AtYD GAMBLING ENFORCEMENT DIVISIO[Y
<br />444 Cedar S€., Suite 133, St. Pa.ul, MN 55101-5133
<br />(651} 2fli-7507 FAX (651)297-5259 TTY(651)2&2-6555
<br />W W W.�PS.STATE..MN.US
<br />Attachment A
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<br />APPLICATION FOR OFF SALE INTOXICATTN� LIQUOR LICENSE
<br />No license wiFl be a roved or released until the $20 Retailer 1D Card fee is received
<br />WorEcets coanpensation insurance company. Name 5 f` Policy # /�� r% %
<br />Licensee's MN Sales and Use Tax I.b # � ,S�% To applyfor a MNsales and use lrlx ID #, call (651} 296-618!
<br />Licensec's Fed.erai Tax ID # — /
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<br />If a cor nration, an oflicer shall execute this � licati.on If a artnershi , a artner shall execute this a licat�on.
<br />Licensee Name (individual arparation Partnership, LLC) Social 5ecurity # Trade I�ame or D8A
<br />�'t � 6�7 Gt%i n�e �- �,�� fs ,�� . �. _ . _ �'1 f/�] Gr/ine �- � ir�'fs
<br />Lite�se Location (,�ireet Address Block No.} License Period Applicant's Home Ph�ne #
<br />� � � �j �1����aL1-� � . � From /%�� Q� To% �.��'i� � /Q � - _.
<br />C�tY�J Co ty State Zip Code
<br />i"105� v� l�� 5 /�-1� .�S//3
<br />Name of� Store Manager Business Phone Number DOB (Individual Appiicant}
<br />T�.� I Uo h.� n�`� .�-
<br />If a corporation or LC,C sta#e name, date of 6irth, Sociai 5ecurity 1€ address, Citle, ar�d shares held by cach officer. If a partnership, state
<br />names, address and dale af hirth of each �arfner.
<br />P�tner Officer {�rst. middle, last) l�f)R SS#} T--' � 5hares A��W�-- ^ � —
<br />1-e�r�cc J �s � I,
<br />Pa�iner Offcer (First, middle,
<br />J � f (�-� L�Q.(%�
<br />Partner Officer {FirsY, middle,
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<br />�OB
<br />I/�'1 •
<br />� DO�
<br />SS#
<br />SS#
<br />Shares � A�+�w��� r:�,. c...«� �;,, r��
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<br />Shares I Ad�ress, C'ity, 5tate, Zip Code
<br />Partner Officer (First, middle, last) DpB SS#� itle Shares Address, City; State, Zip Code
<br />1. If a corp��°~--- '--•- -` ��- - �ratian — ; state incorporated in /�/�
<br />' , amount paid in
<br />capita] _� sUbsidiary of any other carporation, so s€ate and give purpose af
<br />corporatian �� lIGl�Ul � __ . If incorporaied under the la�vs of another state, is carporaliori
<br />aaihorized to do bus[ness in the s te of Minnesota? �1 Yes � No
<br />2. Descr e preii�ises to �i�hich license applies; such as (first floar, secand floor, basement; etc.} or if entire building, so state.
<br />Y`f�' -F�OD�
<br />3. ]s estabJishrnent located near any sfate university, siate haspital, training schooE, reformatory or prispn? CiYes �To If yes state
<br />approximate distance.
<br />4. NamP a.,rl arl�irP�� nfh�,.l.�;nn .,�x,.,Pr•
<br />Has owner o u� mg any connection, irec[ y ar mdirectly, w�th appiicanr! u r e�� o
<br />5. Ts applicant or any of the associates in this application, a member o£the gaverning bady o#'t�e rimunicipality in �vhich this licens.e is
<br />to be issued? �i Yes �<No If yes; in ��hat capacity?
<br />6
<br />7
<br />5tate �vhether any person oth.er than applicants h s any right, titie or interest in the furnit�sre, fixtures or equipment l��r which ]icense
<br />is applied and if sa, give name and details. ��
<br />�H ve applicanis any inierest whatsoever, directly or indirectly, in any ther liquor establishmen in the srate of Minnesota?
<br />Yes C:� No If yes, give name. and address of establishit�ent �� �����
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