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t . <br /> 10/04 APPLICATION FOR RENEWAL OF ANNUAL INTOXICATING LIQUOR, <br /> WINE, 3.2 PERCENT MALT LIQUOR, AND SETUP LICENSES <br /> City of Orono <br /> 2750 Kelley Parkway <br /> � P,O, Box 66 <br /> ����, Crystal Bay, MN 55323 <br /> Phone: (952) 249-4600 <br /> Direciions: Tl�is form must be filled ouf wifh typewriter or by printing in ink. lf the application is by an <br /> individuaf person, by such person; if by a corporation, by an officer thereof; if by a partnership, <br /> by one of fhe partners; if by an associafion or corporation, 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 ($100.00) <br /> ❑ Sunday Liquor ($200.00) � 3.2% On Safe ($100.00) <br /> ❑ Off Sale Intoxicating ($�50.00) ❑ 3.2% Off Sale ($50.00) <br /> License year: 2005 (January 1 — December 31) � <br /> 1. Name of appiicant/(icensee (name of individual, partnership, association or corporation): <br /> .,� �, <br /> ��`����-�— ���� ��-� l � t t��'�`��s ���r� <br /> � <br /> Business Trade Name �.�� ����'<<�� �"'�'�� �, �-��'`"'i L �i�� • <br /> � `� � � N7 � � �r� � �== <br /> Business Address `�J�� l�'. � �'E�1 r'. �3�'L�<,��:�.,/�r�� �5:3�:�/ Phone 7.S - r �.. - 3�'� I <br /> (Streel) (Ciry) (Z�P) <br /> �7 '��i', v�� • �}t+';i.�rlC`l ��,1/�/ ',S�.� ��.�� � <br /> Mailing Address (if different) � �G ��', -����f�= <br /> (5lreet) (City) (ZiP1 <br /> !icens�e's Minnesota Tax l�+entification R!�mber �'��� ! - ��'-j + <br /> Licensee's Federal Tax Identification Number `�� ' ��'f � �' �� �� <br /> 2. If the above named licensee is an individual, complete the following: <br /> ,, ; - , �, <br /> a �� J� ' �'�Vl �� " �d �/L�C`N��.��1�''C_��1 P �� <br /> �Cl '1� <br /> Individual Name {First) (nMiddle) (Last) Date of Birth <br /> ('t,' �.,`� j��li�.: .�}�- , �'vi.: j ��`L;(.:i"l��Lti .f/J/�"I ....\ .l. "' C�� . <br /> Home Address (Street) (City) (Zip) t Home Phone <br /> If the above named licensee is a partnership, association, or corporation, complete The following for <br /> each partner/officer: <br /> a, <br /> PartnerlOfficer Name (First) (Middle) (Last) Date of 6irth <br /> Home Address (Street) (Cib�} ;Zip) Home Phone <br /> b' Ri�ddle (Last) Dz:e or Birth <br /> Pariner/Ofiicer Name (�irsi) ( '' i <br /> Home Address (Street) (Cit;�) (Zio) Home Phone <br /> C. <br /> P2rtn?r!Ofricer Nzme (Firsr) (Middlel (Last) Date o�Bir.h <br />