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Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION;
<br />444 Cedar St., Suite 133, St. Paul, MN 55101- 5133sc
<br />(651) 201 -7507 FAX (651)297 -5259 TTY(651)282-6555
<br />W W W .DPS. STATE..MN.US
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the $20 Retailer ID Card fee is received
<br />Workers compensation insurance company am e Policy #
<br />Licensee's MN Sales and Use Tax ID # To apply for a MN sales and use tar ID #, call (651) 296 -6151
<br />Licensee's Federal Tax ID # ,
<br />If a corporation, an offic shall exec this application If a partnership, a partner shall e xecute this application
<br />Licensee Name (Individual, Corporation, Partnership, LLC) Social
<br />License Location (Street Address & Block No.) e
<br />UIA \5 From
<br />r;r., County
<br />Name of Store
<br />To
<br />Business Phone Number
<br />Trade Name or DBA
<br />1 Ua 'one
<br />Applican Home P ,25
<br />h #
<br />b 4
<br />1 • `!
<br />State Zip Code
<br />mIJ 5
<br />DOB (Individual Applicant)
<br />. t - - ^ W -
<br />If a corporation or LLC state name, date of birth, Social Security # address, title, and shares held by each officer. If a partnership, state
<br />names, aaaress and uu Of ..•. �.• u_ � »�•• r•-• _.___.
<br />Partner Officer (First, middle, last)
<br />DOB.
<br />SS#
<br />ea.
<br />Shares
<br />l ddre, Cty, State, Zip Code
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<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />ritle
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />i. If a corporation, date of incorporation , state incorporated in �11r1(1� , amount paid in
<br />capital . If a subsidiary of any other corporation, so state and give purpose of corporation. . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? ❑ Yes ❑ No
<br />2. D re 'se to which license applies; such as (first floor, second floor, basement, etc.) or if entire building, so state.
<br />3. Is establishment located near any state university, state hospital, training school, reformatory or prison OY es )<No If yes state
<br />approximate distance.
<br />Name and address of building owner:
<br />Has owner of building any connection, directly or indirectly, with applicant? ❑ Yes No
<br />5. Is applicant or any of the associates in this application, a member of the governing body of the municipality in which this license is
<br />to be issued? ❑ Yes XNo If yes, in what capacity?
<br />6. State whether any person other than applicants has any right, title or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, give name and details. rNonP
<br />7. Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />0 Yes <No If yes, give name and address of establishment.
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