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Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br /> 444 Cedar St., Suite 133, St. Paul, MN 55101-5133
<br /> (651) 296-6979 FAX (651)297-5259 TTY(65 I)282-6555
<br /> WW3V.DPS. STATE.. MN.US
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<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
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<br />Workers compensation insurance company. Name
<br />Licensee's MN Sales and Use Tax Il) #
<br />Licensee's Federal Tax ID #
<br />If a corporation, an officer shall execute' this application
<br />
<br />No license will be approved or released until the $20 Retailer ID Card fee is received - :' f(.~,
<br /> Policy #
<br /> To apply for a ~ aales and use t~ ID ~, call (65D 296-6181
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<br />Licensee Name (Individual, Corporation, Partnership, LLC)
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<br />License Location (Street Address & Block No.)
<br /> q/-zq /4w f
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<br />Name of Store Manager Business Phone Number
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<br />ff a corporation or LLC state nqme, date of birth, Social Security # address, title, and shares held b
<br />names, address and date of birth of each partner.
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<br /> If a partnership, a partner shall execute this application.
<br />Social Security # Trade Name or DBA
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<br />License Period Applicant's Home Phone #
<br />County State Zip Code
<br /> BOB (Individual Applicant)
<br /> each officer. If a partnership, state
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<br />Partner Officer' (~irst, middle, las~). DOB, . SS#~ Tide Shares Address, City, State; Zip Code
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<br />?armer Officer (First, middle, lastingS) DOBSS~~ Title Sh~e~a' Ad&ess, CiW, Sta~,~ip C~e
<br /> Ci , Zip
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<br />Ea~er Officer (First, toddle, la~) DOB SS~ Titl~ Sha~s Ad.ess, Ci~, Stye. Zip Code
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<br />1. If a corporation, date of incorporation , state incorporated in /~Zl/ . , amount paid in
<br /> capital . If a subsidiary, of any other corporation, so state /~.t'~'& and give purpose of
<br /> corporation ~ . If incorporated under the laws of another state, is corporation
<br /> authorized to do business in lhe state of Minnesota? L/Yes t~ No
<br /> Describe premises to which license applies; such as~ second floor, basement, etc.) or if entire
<br /> building,
<br /> SO
<br /> state.
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<br />Is establishment located near any state university, state hospital, training school, reformatory or prison? IJYes ~No If yes state
<br />approximate distance.
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<br />4. Name and address of building owner: ~Op'~)&/'~I~ :fi' TODC4[4t3'~ '2'7-~fOO M~'A°90/$aUPrC~'~'
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<br />Has owner of building any connection, directly or indirectly, with applicant'? LI Yes ~I No
<br />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 ~No If yes, in what capacity?
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<br />State whether any person other than applicants has any right, rifle or interest in the furniture, fixtures or equipment for which license
<br />is applied and if so, give name and details, fi/0/a'.¢~
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<br />Have applicants any interest whatsoever, direcfly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />)~ Yes t_l No If yes, give name and address of establishment. /~C~ ~/~q~'~/)~-~Z.~ /v/>/~r/,/4zg /~
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