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Miunesota [)e�,arUnent of Public Safcty
<br />LIQUOR,CONTROL DIVISION
<br />444 Ce�iar St., Suite lOp L, S't, Paul, MN 55 10 1 2 156
<br />(6l2)2hC-6430 "1"(Y(6l2)282-G555
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<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license ti�'ill bc ap�rnvod or released until the S20 Retailer ID Card fec is �eeeived by MN Liquor Contra(.
<br />Warkerscompeusation insurancecompany. NatnC
<br />LICENSEE'S SA1,,C:S �c (1Sti TAX ID #—
<br />_If a corporation, an officer shall execute this appl�
<br />l.icensec: Name (ludividttAl, Corporation, Partn��rsliip)
<br />4.�����" �1�: w � �,.�s �� f�'� ��+,'��C
<br />1. ic�n �+c l .i�elio�t [{,�,_�i �4�d[�x� � f�lo�k ?�f�.]
<br />��� ��f�i"���,i�f �F "'�
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<br />Nam� of Store Manager
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<br />Policy# _ _ . -
<br />To apply for sales tax �, cu3l 296-061$1 or 1-800-657-3777
<br />If a partnership, a X
<br />Trnde N arue or DHA
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<br />[.iccfi�c 1'�ris�d
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<br />C�rom ����� To
<br />shall execute this abblication.
<br />COUTlij� - ��
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<br />f3usuie�s �i� Number DOB
<br />��� ��� -7Y1''.�
<br />1�' $ corporation, state name, date of birth, address, title, and shares held by each officer
<br />names, address and date of birth of each partner.
<br />Paru��,�rOfiiccr(First,middle,tast) L��� '}��1�C S1�aces �����^ �'"�� s`*-'° "��-'�a^
<br />��������'� ��'�� ���rt � ��`4°� �'�'� .
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<br />Iti� I]L'BSIE�Y I I�1I', �S�f,ijL�
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<br />COdC
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<br />If a partnership, state
<br />kre�tatr �I�r �L'ir�i. rri�ld}c, le.�'�
<br />������� �� � ����}�
<br />�}�,s�ti� cx�� �� �. �,�d�i� �a��
<br />Partucr �i�r (k'irsf, middle, last)
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<br />DOB Title
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<br />Ad�rc�s. ���}�, �+��, r,q� �!Y 111
<br />State,
<br />L If a corporation, dale of incorporation ��� ��� . state ineotporated i� ��r�rr.��`d � , auxount paid tti
<br />capital . If a s�c1��'�- � ot� oi��' o�rp�r�Li�n, so state and �� purpose of
<br />corporation �.��s� �r� ���� . I�ivaoa�orated undcr the laws of another state, is corporation
<br />authorized to do �usiness in tl�e state of Minnesota? C� Yes Cl No
<br />2. LSLSLT�,�r�rrii- � +��i� li�s� �p �cs; �,�b �s {�u �kxK. ��,d� ,J�1,�r, ��� �o-i, b�.�1F�r �a�irt R,a;Ld�;�� .�a �ibd.c. !
<br />�l�S'� ���u: _ rr._ ��� � �, r_. _4� � ��e.�J T�_�7s_ �. r- ��d� �f�s�a �f�'1�
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<br />!s ���Lid�b�' ��l�d mo� �c}� �al� � �+8r��� F �I�e ]���a3. I�afam� sr��ol, nte��ccy o� pre�n? ❑ �os �}'�fo ECXee
<br />,•,a- ; .�� � :x�� ; i�t-' istance. __ — -
<br />l,�ra,i� ��; a�:.,��:c:� ..' 1�ai1d'm g �wr.xr:_ r� s � ���r-��� � ~ ....� .-+�' i <' ��vrJ���
<br />��+f� �r�drtrs�r� f��� 'it+�i3d�o���r��,directlyorind'uoetty,withapplicant? ❑Yes�7�l�
<br />�s app�ic�� � en}� � k� u�s m this applieation, a metnber of the govcrnmg baly of�ja4municipality in which Ihis licevsc
<br />�����o i�cd? �] 1�os Na -3�'�r.s, i� whm ��}'? � - - - - - — ---
<br />��� +���Q � p�� �._ �5� e�?pliceuLh �es r,u�r eG�4� or uite.reit i'� the furniture,%xtures or equipment for which
<br />Liee��c is �p� and iF� �camtr.� �d.�1�.o�ls. ���
<br />F��k'� applicantsany interest whatscever, directly or indirectly, ui �y a+.� ]iqu r��L'�m�1 m�� si�d� or�iiaa�sufa?
<br />,�Yes tJ No If yes, given�ne and addressof establistunent. ���,�,�I��_, __. ___ __, _,
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