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PERMIT FEE $151.50 <br /> <br /> MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br /> LIQUOR CONTROL DIVISION <br /> 333 SIBLEY ST. PAUL, MN 55101 <br /> <br />APPLICATION FOR PERMIT TO ALLOW ONLY CONSUMPTION AND DISPLAY OF INTOXlCATI <br /> <br />'DBA or Trade Name <br /> <br /> PHONE 612-296-6159 <br /> <br />.pplicant Name (Business, Partuershlp, Corporation) <br />' NL: T?' /7'o © /// <br /> <br />Street Address <br /> <br /> __Private Club bllc Business <br /> <br />Name o! Business or Club Manager <br /> <br />of Building Owner <br /> <br /> Business Address <br /> ? /o <br />ICounty tale 1ZiP Code <br /> <br /> T~De of Bu~Ine~ (RestaUrant, ~nce H~IL e~c.) ' <br /> ~dre~ o~ ~n~ger <br /> <br /> THE CLUB OR BUSINESS PREMISES SEP. ARATE FROM <br />ARE BUSINESS ESTABLISHMENT? ~Yes [~No ANY <br /> <br />IBusiness Phone <br /> <br /> (hz2 <br /> <br /> Address of Owner <br /> <br /> / <br />IHAS OR WILL A NON-INTOXICATING MALT LiQUoR LICENSE BEEN ~SsOED <br /> TO THIS BUSINESS FOR THIS LOCATION? <br /> L~-No <br /> <br />,~ APPL,CA~,ON I,F'rRANS~, ~OR~ER UCENSEES NAME AND BUS,N~SS TRAOE NA~E <br /> <br /> FOR A PUBLIC BUSINESS: <br /> <br /> liaPartnersl~ip, State the Name and Address of Each Partner If aCorporation, Statethe Name and Address of Each Officer. <br /> <br />Address <br /> <br />Address <br /> <br />Business Partner/Officer <br /> ,P/ T£ / O l.4 .,4. <br /> <br />Business Partner/Officer <br /> <br />3osJness Partnex/OfHcer <br /> <br />Date Club Organized <br /> <br /> Club <br />At. Present Location: <br /> <br /> JDirect or Name <br /> <br /> FOR A PRIVATE CLUB <br />JNunrber O' Members Amount of Dues JMe,n~ershi. Requirements <br /> <br /> i ls Club Building Does Club Maintain Lockers <br /> Owned or Rented? For Members To Store Liquor? <br /> <br />Address <br /> <br />~Yes [] No <br /> <br />Club Officer/Director Name Address <br />Club Officer/Director Name Address <br /> <br />Has applicant; if partnership, any partner; if corporation, any officer or director; if club, any club officer or director, ever <br />had a license under the Minnesota Liquor Control Act revoked or suspended or been convicted for any violation of State <br />Laws or local ordinances; if so, give date and details <br /> <br />I hereby certify that the answers are true of my own knowledge and understand that the giving of false information or the failure to give pertinent information <br />constitutes cause for revocation of this permit. ANY PERMIT ISSUED HEREUNDER DOES NOT ALLOW THE SALE OF INTOXICATING LIQUOR. <br /> <br />NO CONSIDERATION WILL BE GIVEN TO THIS APPLICATION <br />UNLESS APPROVED AS PROVIDED BELOW: <br /> <br />IF THE BUSINESS IS LOCATED IN A COUNTY: <br /> <br />Approved - Chairperson County Board or Representative Date <br />IF THE BUSINESS IS LOCATED IN A MUNICIPALITY <br /> <br />Signature -- Authoriz'ed Applicant <br /> <br />Date <br /> <br />IF A CLUB ATTACH A COPY OF THE CONSTITUTION AND <br />BYLAWS OF THE CLUB AND A CURRENT LIST OF <br />MEMBERS. <br /> <br /> CASH, <br /> <br />CHECK <br /> <br />Approved - Council President or Representative Date <br /> <br /> <br />