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<br />Name of Store Manager
<br />Partner Officer (First, middle, last)
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<br />Partner Officer (First, middle, last) '
<br />artner Officer (First, middle, last)
<br />Partner Officer (First, middle, last)
<br />Minnesota Department of Public Safety
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
<br />444 Cedar St., Suite 133, St. Paul, MN 55101 -5133
<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 INTOX ICATING LIQUOR LICENSE
<br />�T' �i�enseiavtllitie ,.apprave.,d(`gt' releas��ttntrl. Tr .
<br />Workers compensation insurance company. Name
<br />Licensee's MN Sales and Use Tax ID #
<br />Licensee's Federal Tax ID #
<br />If a corporation, an officer shall execute this application
<br />Licensee Name (Individual, Corporation, Partnership, LLC)
<br />Yet i ta Jiti.ri e'tt C_
<br />License Location (Street Addess & Block No.)
<br />7/ 1-1 N' J
<br />City
<br />(YI (x, f ee-L & Vc t2W
<br />If a corporation or LLC state name; ate of birth, Social Security # address, title, and shares held by each officer. If a partnership, state
<br />names, address and date of birth of each partner.
<br />DOB
<br />DOB
<br />Policy #
<br />To apply for a MN sales and use tax ID #, call (651) 296 -6181
<br />Social Security #
<br />License Period
<br />From To
<br />County
<br />F rtok4-
<br />If a partnership, a
<br />t•
<br />Business Phone Number
<br />76'3 • LI 33 F5
<br />SS#
<br />SS#
<br />Title
<br />artner shall execute this application.
<br />Trade Name or DBA
<br />i'n & 1 L I li 1,t, 0 r
<br />Applic is Home Phone #
<br />I State
<br />Title •
<br />Shares
<br />/0
<br />Shares
<br />n
<br />L i m r+e r.� L i `44,,i C.w t'''1 P P state incorporated in 1 V I ;v1 f 1 ZSt� 1� ,amount paid in
<br />If a corporation, date of incorpo ationtrl :a. 0 and give purpose t a
<br />capital t l 3 b , & c. . If a subsidiary of any other corporation, so state
<br />corporation . If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? ❑'Yes ❑ No
<br />Describe premiss to which license applies; such as (first floor, second floor, basement, etc.) or if entire building, so state.
<br />712 f - w - l n NIA,/ . /J,,j f ft d A c >-2 � (2rAu q
<br />Is establishment located near any state university, state hospital, training school, or prise %Yes ❑ No If yes state
<br />approximate distance. 4Tl f<a /Pr Hn� [Cc % (, C ^ ff y e 2°d eAi" 07 .-, i /ett
<br />/1 L L G /.L Gj
<br />Zip Code
<br />DOB (Individual Applicant)
<br />Address, Ci , State Zip Code
<br />Address, City, State, Zip Code
<br />Address, City, State, Zip Code
<br />Address, City, State, Zip Code
<br />A fl J _7Zweh
<br />Name and address of building owner: 73; T
<br />.,°ta_ y0 4f /r 4/ 41' ° E £:lv i MA/
<br />° as owner o •ui • ng any connection, , erect y or m erect y, wi app scan . ❑ es ❑ o
<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 o If yes, in what capacity?
<br />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. , i 71'11
<br />Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />❑ Yes If yes, give name and address of establishment.
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