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ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br /> 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 <br /> Fax (651) 297-5259 <br /> (651) 296-9519 TTY (651) 282-6555 <br /> WWW.DPS.STATE.MN.US <br />APPLICATION FOR COUNTY ON-SALE INTOXICATING LIQUOR LICENSE <br /> <br />No license will be approved or released until MN Liquor Control receives the $20 Retailer ID Card fee. <br /> <br />Workers Cmnpcnsation Insurance Company <br />i,ICENSEE'S SALES & USE TAX ID # <br />IACFNSEE'S I:[£DF~RAL TAX 1D # <br /> <br />Applicant,'s name (Business, partm <br />l,iccnsc address <br /> <br /> Policy # <br />To apply for MN sales tax number call 651-296-6181 <br /> <br />Social Security # DBA or trade <br /> <br />Business phone <br /> <br />Applicant's home phone <br /> <br /> , .,,-. ~ ! .., ,,Il.,/ <br /> ~oun~ [ State Zip ~de ' License period <br /> <br />Give name, residence, DOB, Social Securi~ ~, title and age for all partners, or the officers and directors of a partnership or <br /> <br />corporation, and the percent of stock held by each officer ifa ,iicable. <br /> <br />Name / / Social Security# <br />Address <br /> <br />city~ <br /> /< <br /> <br />Nanlc Social Security # Title <br /> <br />Address City <br />Name Social Security # Title <br /> <br />Address <br /> <br />Date cfi' lncorpmation State of incorporation <br /> <br />Purpose of corporalion <br /> <br />City <br /> <br />DOB <br /> <br />DOB <br /> <br />DOB <br /> <br />Percent stock or partnership interest <br /> State <br /> <br />Percent stock or partnership interest <br /> <br /> IState <br /> <br />Percent stock or partnership interest <br /> <br /> State <br /> <br />Certificate Number <br /> <br />Is corporation authorized to do business in Minnesota? <br />DYes [] No <br /> <br />subsidiary of another corporation, give name <br /> <br /> · l)cscribc premises to be licensed (location, facilities). <br /> <br />Fhmr cstablishment is located on Seating capacity <br /> <br />Number ot' months per year establishment will be open <br /> <br />IHours food will be available I Number of people restaurant employs <br /> <br />Name of manager <br /> <br />If this restaurant is in conjunction with any other business (resort, etc.), describe the business. <br />Name thc nearest municipality in which On Sale licenses are issued. <br />[las applicant, partners, officers or employees ever had any Liquor Law violations in Minnesota or elsewhere, including State <br />Liqam' Control Penalties? Yes ~Ifyes, give date, charges and final outcome. - <br />Is thc ach!leant or any of the associates in this application a member of the County Board in which the license will be issued? <br />Yes (~a~f yes, in what capacity? .(If the applicant for this license or any of the associates is the spouse of a <br />member of thc governing body or where a family relationship exists, the member shall not vote on this application.) <br />/No 6. ltave the applicants any interest, directly or indirectly, in any other liquor establishment in the county or any city <br /> in the county issuing this license. If yes, give the name and address of the establishment. <br /> <br /> <br />