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10/04 APPLICATION FOR RENEWAL OF ANNUAL INTOXlCATING 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 /> Directions: This form musf be filled out with typewriter or by printing in ink. !f the applicafion is by an <br /> individual person, by such person; if by a corporation, by an officer thereof; if by a partnership, <br /> by one of the paitners; if by an associafion or corporation, by the manager or managing <br /> officer. <br /> License type: (check alf 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) [�'��.2% On Sale ($100.00) <br /> ❑ Off Sale Intoxicating ($150.00) ❑ 3.2% Off Sale ($50.00) <br /> License year: 2005 (January 1 - December 31) � <br /> 1. Name of applicant/licensee (name of individual, partnership, association or corporation): <br /> ��1� �t�`F`F�i�l F-��e �'C iz <br /> Business Trade Name D �''c��� �u����c �c�-� �c: cc f^sc� <br /> � �� Ga1Rv���� �.��� Phone iS� `�73 y�'�E'y <br /> Business Address �� � �'c�,r� CJ��cl1• � <br /> (Streeq (City) (Zip) <br /> Mailing Address (if different) �c�( �� Cr�S'��� �i�u -����'��3 <br /> (Slreet} f (City) ' (Z�P) <br /> I ���ngoc'S �,/ljnnpcpt� TG� Irlgr�tifjratinn �liimhar <br /> Licensee's Federal Tax Identification Number <br /> 2. If the above named licensee is an individual, complete the following: <br /> � <br /> a. ���►�1 c� � •� r �.5 7`� � �c �11 <br /> Individua N me (First) (. iddle) ` (Last) Date of Birth <br /> �s�6 � ������-f- s-'t iti��r� l� �' c�t�� ����Si <br /> Home Address (Street) � (City} (Zip) ome one <br /> If the above named licensee is a partnership, association, or corporation, complete the following for <br /> each partner/officer: <br /> a. <br /> Partner/Officer Name (First) (Middle) (Last) Date of 8irth <br /> Home Address (Street) (City) (Zip) Home Phone <br /> b. <br /> Partner/Officer Name (First) (Middle) (L2st) Date of Birth <br /> Home Address (Street) (City) (Zip) Home Phone <br /> C. <br /> Partner/Officer Name (First) (Middle) (Last) Date of Birth <br /> Home Address (Street) (City) (Zip) Home Phone "'" <br />