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Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMEbrr DMSION
<br />444 Cedar St., Suite 133, St. Paul, MN 55101-5133
<br />(651)296-9519 FAX (651)29%5259 'ITY(651)282-6555
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<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
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<br />Workers compensation insurance company. Name.. '~z,~¥ AJmln{t~.~'~ Policy#. O°c' 07.-9 qO~'
<br />LICENSEE'S SALES & USE TAX ID # '~>t~c~ w~) To. apply for sales tax #, call 296~06181 or 1-800-657-3777
<br />If a corporation, an officer shall execute this applicatiofi If a partnership or LAC, a parmer shall execute this application.
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<br />Licensee Name (Individual, Corporation, Partnership, LLC)
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<br />License Location (Street Address & Block No.)
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<br />City
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<br />Name of Store Manager
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<br />I I I I
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<br />Social Security #
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<br />Trade Name or DBA
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<br />License Period
<br />From ~¢/r,;~ To l'/~¢o
<br />, ,[
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<br />Business Phone Number
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<br />Ifa corporation or LLC state name, date of birth, Social Security # address
<br />officer. Ifa partnership, state names, address
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<br />Partner Officer (First, middle, last)
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<br />Partner Officer (First, middle, last)
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<br />Partner Officer (First, middle, last)
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<br />Parmer Officer (First, middle, last)
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<br />DOB
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<br />DOB
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<br />DOB
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<br />DOB
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<br />Applicant's Home Phone
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<br />Zip Code
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<br /> --'· I DOB (Individual Applicant)
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<br /> I I IL III II
<br /> rifle, and shares held by each
<br />md date of birth of each partner.
<br /> SS# Title Sham! Address, City, State, Zip Code
<br />
<br />S~
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<br />SS#
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<br />SS#
<br />
<br />Title
<br />
<br />Title
<br />
<br />Title
<br />
<br />Shares
<br />
<br />Shares
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<br />Address, City, State, Zip Code
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<br />Address, City, State, Zip Code
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<br />Address, City, State; Zip Code
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<br />Ifa corporation, date of incorporation ~-~.,,/~'~'~ , state incorporated , mount, paid
<br />In capital S~ ? ?~ ? . Ifa subsidiary ~'fany other corporation, so state ' . and give purpose
<br />of corporation . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Mirm~ota? Yes No
<br />Desc'q_'be premises to which license applies; such as (first floor, s~.ond floor, basement, etc.) or jr entire building, so state.
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<br />Is establishment located near any state university, state hospital, training school, r:£o .rmatory or prison? Yes (~Ifyes
<br />state approximate distance.
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<br />Name and address ofbuilding owner. ~,b Co~o~ ~qlO'/ ~ ~z~tg Btu~
<br /> Has owner of building any connection, directly or indirectly, with applicant? (~ No
<br />Is applicant or any of the associates in this application,-a member of the governing body ot'the municipality in which dais
<br />license is to be issued'/ Yes (~Ifyes, in what capacity?
<br />State whether any person other than applicants has any fight,_rifle or interest in the fum~mrc, fixtures or_equipment for which
<br />license is applied and if so, give name and derails. __ ~NC- ¢ol~Oo~/BTot~ C°eaT~fi~:t-' }~ ~ '
<br />Have applicants any interes~ whatsoever, directly or indirectly, in any other liquor establishment in the state of Mirmeso'
<br /> (~ No If yes, give name and address ofestablishment. '
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