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10/04 APPLICATION FOR RENEWAL OF ANNUAL INTOXICATING LIQUOR,
<br /> WINE, 3.2 PERCENT MALT LfQUOR, AND SETUP LICENSES
<br /> City of Orono
<br /> ��� 2750 Keiley Parkway
<br /> P.O. Box 66
<br /> Crystal Bay, MN 55323 �
<br /> ����� Phone: (952) 249-4600
<br /> Directions: This form must be filled out with typewrifer or by printing in ink. If the applicafion is by an
<br /> individual person, by such person; if by a corporation, by an officer thereof; if by a partnershrp,
<br /> by one of the partners; if by an associafion or corporafion, by fhe manager or managing
<br /> officer.
<br /> License type: (check all that apply)
<br /> ❑ On Sale Intoxicating Liquor ($5,000.00) ,� Club ($200.00)
<br /> ❑ Wine ($2000.00) ❑ Setup (5100.00)
<br /> �, Sunday Liquor ($200.00) ❑ 3.2% On Sale ($100.00)
<br /> ❑ Off Sale Intoxicating ($150.00) ❑ 3.2°/o Off Sale ($50.Q0)
<br /> �.6cense year: ��,.-��--,%^i �Ofl�' (January 1 — December 31)
<br /> 1. Name of appiicant/licensee (name of individual, partnership, association or corporation):
<br /> Business Trade Name ��.�L��l� �.4 ����15��1'��-�J ��1'�L�
<br /> 6usiness Address '���� �'�` Y��'l�s { � L�.r� �`' ��\�i������+��17'l�r��` Jc �1�� ° ��: ` �'�'��
<br /> � , Y� � ��r(�P h o n e �SJ;- ��-�..�--�-�-i �:�.,..�
<br /> (Streeq (CtIY) ,� IZ�P)
<br /> Mailirg Address (if different)
<br /> (Streel) (Ci;y) (Lp)
<br /> I iron�og'c 11/lin�gcpta TGX IrlAntjflG?tiOC? N��fl?b�'I" {•v�l�.�,_����`�a J
<br /> Licensee's Federal Tax ldentification Number ��—�.��0 f�1�i�1.�
<br /> 2. lf the above named licensee is an individual, complete the following:
<br /> �'�x l � �� ���' r�i��t�� ���1
<br /> a. � � .
<br /> Individual Name , (Fjrst),� _ ., (Middie) , � (Last) f Birt�
<br /> �'�j-�-r=i,{� ��.�- `�;`��L�I ���:�`_.;tr�`��.-;��� , {-�(�.a{71 t::LL��'', =.�`>t-!�1�:;
<br /> Home Address (Street) ' (City}_) (Zip) Home Phone
<br /> If the above named licensee is a partnership, association, or corporation, complete the following for
<br /> each partner/officer:
<br /> i�i., ` j 1(`� _
<br /> a, I `Lt�.t) ��.; ;�������il� `��a� .�
<br /> Partner/Officer Name (First) t (Middle) , � c(�_as�� _ �or��Rn
<br /> I��^��� t f ' '� 1-�- �i ;:;�r. ,. .. : � � .��� � �^i��/i . ; '�f . _ _
<br /> �^ y i4'� i,(A � . i .] i� �. � �1 i ..�._�� _.�•_.��_,
<br /> Horr�e Addfess .�Street) ' (City)._� �, (L�p) Home Phone
<br /> rJ. �jj",���y'� �' 1�i��_i ;��`�
<br /> Partner/Oirice,Nzme �(rirs�� (i,,�i:ddle� � (Las � _ C��e o� 6���h
<br /> -.._ =� �: i �; „ . _I ,���a.. i - -r, � :=, c i �
<br /> `{l � _ � �--��rti�. .V I�.l , t J �.� i i l,l 1 1 �_�'�r:t_ i- - !
<br /> home Address � , (S[re�t) (C t%I — ,t f I ;Zio) Hcm� Fhon�
<br /> , �G "� � '':'.�' t'-��i"%', '` _ �'t'' l
<br /> ��r'fl ��C'f��C� ��aRl� (F(a � ���II^d�cl (�25 I ✓c:� Oi �IRfI
<br /> . '� I . i . — - -
<br /> r �, � i -_ \ : `�(i
<br /> �t-�i�, .4 ? .,t �i�:�:�`L ��. . , t' �����1i � 1
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