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<br />Minnesota l}t�i�riiritu� �('Public S�tCct�� � ��'s�,y I
<br />���i LIQUUR,CONTROI.,lliV[SION � �+�4�.y.��
<br />' �14�# Cedar St.. Suite ]0O1... St. Paul, MN 55 :�71-2156 •����: L"
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<br />'�t..�� (612)29G-Gd30 'I"(Y(612)282-GSS5 - ��,,,�;:�
<br />I�F'1'LI�ATION FOR OFF SALE INTOXIC:ATiNG LIQUOR lL10ENS��
<br />LV� liccnsc ��'ill be appru��ed or c�lensed until �hr ��� Retailer ID Cardfee is received b}' M�' Liqu�r Contwl.
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<br />�l'orkcrscompcitsationaux�rr�i�:company. j�I�un� _ Palicy#� .,_���__ . __
<br />[.IC[:NSI:E'S SAI.�S ��'�'_ TAX :i� # --.-.-- -� 1'o apply for salcs �a� #l, ca112�16-06 �{ I c:r ;-�'�;��f:.r7 �l'7 :
<br />If a corporation, an officer shall execute this application If a partnership, a partner shall exec�<<e this application.
<br />l.icensec �;��7ti (Individual, Corporation, Partu�rsliip) �I�radc Name or U13/� � ti
<br />---y�-- — .
<br />SPEEDUId4Y SUPERAMERICA LLC
<br />` I.�;xii;x� ��,; �'��u (S�reet ndciress & I31cx:k No.)
<br />2172 LEXINGTON AVE.
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<br />ROSEVILLE
<br />�'„i�t•of Store Man�ger
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<br />� SUPERAMERICA #^4210
<br />- l.icense Period
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<br />i ��iiitl4• State
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<br />[3usiuess Phone Number
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<br />if a corporation, state name, date of birth, address, title, a��d shares
<br />names, address and date of birth of each partner.
<br />f'arliser Oflicer (First. middle, las�l) '.�0�3 Ti�le S7
<br />PLEASE SEE ATTACHED LIST OF OFFICERS
<br />f'a�-U�cr Ofiiccr (C'ir-s1. middle. (asi)
<br />k'artti�r Officcr First. tniddl�, last)
<br />1'ar-tucr Of�icer First, middlc, last)
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<br />�ta�� lu�vi I'4 I ltini� I'_•i{i_iL
<br />�.i� Codc
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<br />DOB (Indiri�lyi }I r�r�y� I r� a�i; }
<br />held by eacfi officer. If a�artnership, state
<br />ares
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<br />Sl�ares
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<br />� Ad�lress, City, Stale. �ip Code
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<br />AdcL�css, Cit}', Stalc. �ip Codc _
<br />Address, Citti•, Stalc. �.ip Code ��
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<br />� Address, City, St�te, }'.ip Code ��
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<br />If a corporation, date of incorporation _� �� r�_ , stale iucoiporuted in _�, ��=i.�_ . ,, a�llauut paid i� �
<br />capital . ff,-,s�ci�i,�-ti';�':'ar�}'�I�icrt�,xF'•arf�i�n,4o-��� '- = a�i�G���piuposeof
<br />i:: �'•oi �[:;� f"OMI RT N.F S7DRE �i1LR�TA_I1. GAS �AI E5, . If iucor��ort�ted lindcr the laws of miotl�cr si ate, is corporation
<br />authorized to do business in tlie state of Miunesota? �+I Yes C� No
<br />Describe prcmi�;s to which licensc applics; �I�I� as (fir� floor, sccood floor, basemeut, etc.) or iTculire ar.iildii�g, so �(atc,
<br />T� PFRMTT TS APPgQUF S PARAT NTRY TO LIQUOR STORE WALL L�IILL SEPARATE �~'j �� ��T�:_..=��',�,�•�•r��T.�-
<br />�s es�taUli�[uenR ��� ���i� ••�, �� ;�� s�����. �tate un��ersity, statc hospital, training school, reformatos�� or prison? �I Yes C.; No TI'}'es
<br />stntc �pproxu•���c-;�_..:,�;.:, _......R��t'�= '��:I-:��•i.�'':���r���z 5L_.P.:]�7._��N �4TF..�,'�_:�t:�`ti=' �-r� �(�k'"�a� ti--.
<br />N�1111C 711(11;r'f� � :-�:11����ti'vi�}r.rr.� �-���r�ii�_ �•J�xrS�'����"�; . � �� r�
<br />__ _ __ Flas o�vuer ot�biiiluu�g aey cou�iection, irect or u� {�. ,�v a��;�licant? �'.! Yes fJ No
<br />:5 applicant or �ry of liit associltcs in this application, a mcmber of tl�c go��cr�ing body of thc municipalii�� in which tl.iis : i�: :•i: kY
<br />is to be is�ied? C] Yes D� No lf }�es, m what capacity? __
<br />State �vl�cthc.�r ;w-. person other ili �ti applic�uts has ru�;• ri�,l►t, titic or u�terc;i in IJI,C farnitiirc, fiYtures or GS � p�ncut for which �
<br />liccnse is applicd wd if so, give n�e and details. h� �
<br />: I�n�= applicanls any inlcres� whatsoever, directly or indirectly, in a�ry other liquor eslablisluueni in the �'a�� ofMi�esota?
<br />.'?D�'t s C:1 No If yes, give o�oa� and address of e� r.S� I i�c1��7�.tii: _ SPEED111d4Y SUPERAMERICA LLC HOLDS (`1�`�Y OF,F SALE 3.2 �._._, .
<br />F3EER LICENSES I N THE STATE OF MINNESOTA ___. __ __. ___�
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