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2.
<br />F� Minnesota Department t3 ' artment of Public Safe ..
<br />:-
<br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION,.
<br />C rOF
<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 />11'- !C
<br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE
<br />No license will be approved or released until the $20 Retailer ID Card fee is received
<br />Workers compensation insurance company. Name Policy #
<br />Licensee's MN Sales and Use Tax ID # 891835 To apply for a MN sales and use tax ID #, call (651) 296.6181
<br />Licensee's Federal Tax H) # 20- 8645566
<br />If a corporation, an officer shall execute this application If a partnership, a partner shall execute this application.
<br />Licensee Name (Individual, Corporation, Partnership, LLC)
<br />Social Security #
<br />Trade Name or DBA
<br />Midwest Wines Inc
<br />388 -76 -7170
<br />License Location (Street Address & Block No.)
<br />License Period
<br />Applicant's Home Phone #
<br />13949 Staint Francis Blvd.
<br />From � � o E
<br />�I f
<br />763 - 422 -4855
<br />, � V 1
<br />City
<br />Ramsey
<br />County
<br />State
<br />Zip Code
<br />Anoka
<br />Mn.
<br />55303
<br />Name of Store Manager
<br />Business Phone Number
<br />DOB (Individual Applicant)
<br />Michelle Le Roy
<br />612- 207 -9839
<br />01/31/1959
<br />If a corporation or LLC state name, date 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 />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Michelle Le Roy
<br />CEO
<br />5000
<br />mamp in,
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />t , Q6, State Zip Code
<br />Steven Le Roy
<br />CFO
<br />0000
<br />Champlin, Mn. 55316
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />Partner Officer (First, middle, last)
<br />DOB
<br />SS#
<br />Title
<br />Shares
<br />Address, City, State, Zip Code
<br />1. If a corporation, date of incorporation 03/19/2007 _ ,state incorporated in Minnesota , amount paid in
<br />capital . If a subsidiary of any other corporation, so state and give purpose of
<br />corporation market wine to public If incorporated under the laws of another state, is corporation
<br />authorized to do business in the state of Minnesota? I Yes U No
<br />2. Describe premises to which license applies; such as (first floor, second floor, basement, etc) or if entire building, so state.
<br />south end of building of a three sue building. We will aslo have middle bay for our clothing
<br />3.. Is establishment located near any state university, state hospital, training school, reformatory or prison? UYes k i No If yes state
<br />approximate distance.
<br />4. Name and address of building owner: Mr. Sadiq Punjani
<br />H illswicK Trail n. BrooKlyn ParK, Mn.
<br />Has owner of ui ding any connection, directly or indirectly, with applicant? U Yes *1 No
<br />5. 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? U Yes X No If yes, in what capacity?
<br />6. 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. none
<br />7. Have applicants any interest whatsoever, directly or indirectly, in any other liquor establishment in the state of Minnesota?
<br />U Yes XU No If yes, give name and address of establishment.
<br />-94-
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