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Item#19-CC Agenda 02-12-07 <br /> Licenses[Page 17 of 21] <br /> 10/04 APPLICATION FOR RENEWAL OF ANNUAL INTOXICATING LIQUOR, <br /> WINE, 3.2 PERCENT MALT LIQUOR, AND SETUP LICENSES <br /> 411111111101. City of Orono <br /> 2750 Kelley Parkway <br /> P.O. Box 66 <br /> hr Crystal Bay, MN 55323 • <br /> Phone: (952) 249-4600 <br /> Directions: This form must be filled out with typewriter or by printing in ink. If the application 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 partners; if by an association or corporation, by the manager or managing <br /> officer. <br /> License type: (check all that apply) <br /> P On Sale Intoxicating Liquor ($5,000.00) N Club ($200.00) <br /> Wine ($2000,00) Setup ($100.00) <br /> 'K- Sunday Liquor ($200.00) 3.2% On Sale ($100.00) <br /> n Off Sale Intoxicating ($150.00) I 1 3.2% Off Sale ($50.00) <br /> License year: 2005 (January 1 — December 31) • <br /> 1. Namepplicant/licensee (name of individual, partnership, association or corporation): <br /> 1 (ikAA ntlAtAAAZ <br /> Business Trade Name c'€trtA <br /> Business Address .jf 1 i,-,:vi �'' ' 4 > i Phone ci>�' (1J-1SU'0 <br /> (Street) (City) (Zip) ' <br /> Mailing Address (if different) <br /> (Street) (City) (Zip) <br /> Licensee's Minnesota Tax Identification Number14 ZSA <br /> Licensee's Federal Tax Identification Number 41 -1-g >ci'g I <br /> 2. If the above named licensee is an individual, complete the following: <br /> a. <br /> Individual Name (First) (Middle) (Last) Date of Birth <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 /> ii <br /> a. I"1��1 c�43 ti3 `-t" r,VqS Dt'x-�/--A <br /> Partner/Ocer Name First) Middle) (Last) <br /> Home Address ___(S-treet) ;City) (Zip) <br /> b. ( (it I kt.�,ti:,�r 014/I)(4' <br /> Partner/Officer Name (First) jrvliddle) o (Last) ,- <br /> K 5D .r l o-11 tm i i f iv/ Dirt ( vvil 141,1"E f5C°Home Address //)� (.Sjreet) (City) <br /> C. PitLI�Cva,� 161- lsyA_i — <br /> Partner/Officer Name (First3_ (Middle) (Last) <br /> Home Address (Street) (City) (Zip) Home Phone <br />