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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)296-9519 FAX (651)297-5259 TTY (651)282-6555 <br /> <br />,'3'[I{.FFT .AIt31')I~F,~S <br /> <br />NA~fl;i O1[" PER.SON MAKING APPI'.[CATI'CtN <br /> <br />DATES LIQ.L;'O,I~ WIILL <br /> <br />¢)[~.(L,\N'IZA'TN)N OF'F'iCER'.~ N'/'~.NI]( <br /> <br />D'A1 ~: 3,1~(.~/~,.N~ZJ3. D TAX E~t ~[ N[;M.IJEI.~ <br />C[~" ST'ATE 1 ZJP CODE <br />I <br /> <br />['YPI( OF OR(JANIZATrON <br /> · (, r, Ol'! <br />~.; CL!..~ ~C'~-LkRIT'~$~LE "l REL[ slObS 'l <br /> <br />(')R,~'t,A N!?D,.T[ON OFI:r]cER"S NAME <br /> <br />J ,~D I)~,~.[!,cc, 5,~ <br />1 <br /> <br />Will Ibc av,plka,~ can.'3' liquor liabiliJy i,e..mraacc"? if so. thc <br /> <br /> APPROVAL <br />APP'IJiCA'I?IlON M.L:'$T BE APPROVED gk' CiTY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROl[, <br /> <br />C[T Y/COU~'NTY <br /> <br />CITY FEE. AMOL;NT <br /> <br />DATE FEE I?A[D <br /> <br />S~(~NA'rt JR[.; CI'TY CI' lE~ ()I{. COUNTY (],HriCIA [. <br /> <br />i)A'I?E A, PI?R.OVED <br />IACENSE I)ATES <br /> <br />LIQUOR c': ONTROIL DI]~.LC.'OIL <br /> <br />not ~¢~nrate l:h¢.~e two parts, a&,ncl both pa~. ~o the a.dffres.n Mm. Ye ~ntl the ~}ri[gh~a.[ sign.ed b~' ~hb di'v~im~ <br /> <br /> <br />