9.a) Liquor License Application_The CreameryAPPLICATION FOR ANNUAL LIQUOR LICENSE
City of Scandia, Minnesota
14727 209th Street North, Scandia, MN 55073
Phone 6511433-2274 Fax 651/433-5112 Web http:/twww.ci.scandia.mn.us
This application form is for use to provide information required by the City of Scandia to supplement license application
forms required by the Minnesota Department of Public Safety/ Alcohol and Gambling Enforcement Division (ALGED) for
on -sale liquor licenses, as provided by City Ordinance No. 93. Print, type or check all applicable information. Attach a
check in the amount of the license fee plus the required investigation fee ($500.00) payable to the City of Scandia.
License fees may be pro -rated on a quarterly basis. Any unused portion of the investigation fee will be returned to you
following either approval or denial of the license. All licenses issued are valid for a calendar year. Contents of this
application are public information.
1. Type of License:
3.2 % Malt Liquor On -Sale ($150.00)
3.2 % Malt Liquor Off -Sale ($50.00)
Off -sale Intoxicating Liquor License ($100.00)
_ On -sale Intoxicating Liquor License ($2,000.00)
Sunday On -sale Intoxicating Liquor License ($200.00)
Combination On-Sale/Off-sale Intoxicating Liquor License ($2,500.00)
On -sale Wine License ($500.00)
2. Name and address of establishment:
Name: Tki, �Cael f' C �f_awePI
Street Address: Z jZ_ _7q 01 4,, T ra r I No,, f�
City/ State: S Co d d ti, m N 4�S 07 3
Phone: Co S' -f - '/98' - Oq 7/
E -Mail: 1v 09 SCayd!ti tfeopfevy,C
zip: SSD 73
3. Describe the business and the premises in which it will operate:
hall r✓+ hall V 1' g , � 4
6(04P- 010tM
ajar a pie*
Pet-
4. Proposed date of opening:
�� �I USf �� . -,70y.7
ra
5. Do you currently hold a liquor license in any other location? _ Yes No
If "yes", please list the name of the establishment, address, and years in business at this location.
6. Federal Tax Identification Number: / J � ^ 3'15
?b /7
7. Name and address of owner #1—business address:
Name: &Pf F j k r P r i sQ5 ) 0 f✓
Street Address: ? QO Z P u f S� C,1'e&[6 1 c a j
City/ State: (stipOJ�o f j, MN
8. Name and address of owner #1—residence address:
Name: f* ULe,,,( T 6 � „, Pa
Street Address: WO Z M A I_S k CWJ& V a
City/ State: („ � p Oj 6V r ,� N
9. Name and address of owner #2—business address:
Phone: tis/ - ZqS—_ 605:e, -
E -Mail:
gS:e,-E-Mail: V+1 r4i Z A Nn QaPP� gA�ta //co
U
Zip: 5517 S
Phone: 2A 5- - (e e_4;�
E -Mail: lM r G Z V) ��''�` e.c v,t
Zip: ss/ ZS
Name: �awe_ q S -7 Phone:
Street Address: E -Mail:
City/ State: Zip:
10. Name and address of owner #2—residence address: //�
Name: V_ 6 H L 2 , p� Phone: � 5/ - 215 ._ 0 g Z Z_
Street Address: R'06 Z M(W �- GI( E -Mail: We p 6 ,pf 9 015n. ezm
City/ State: IN (}fid Yl of y N Zip: 5T I ZS'
City of Scandia, Application for Annual Liquor License
Page 2, 7/6/2015
ACKNOWLEDGEMENTS: I declare under the penalties of perjury and criminal liability for willfully
making a false statement that this application is, to the best of my knowledge and belief, true, correct
and complete. I further acknowledge that I have receive a copy of Scandia Ordinance No. 93
governing liquor licenses, and that I am familiar with and agree to abide by its requirements.
In addition to this form, AGED Form "Certification of an On -Sale Liquor License" shall be completed
and attached, with all required documentation including but not limited to a certificate of Liquor
Liability insurance and releases from all owners, partners or officers required to complete
investigation of the license application. No application will be considered complete until all required
forms have been submitted and the fee has been paid.
11. Applicant S nature(s)
-pit�-
Application & Fee Received
City Council Consideration (Date)
Approved
For City Use Only
7 -4 -go/ -5
Denied
r)- aI-- a0 /5
City of Scandia, Application for Annual Liquor License
Page 2, 7/6/2015
Date:
TO) I C, z�i s-
�,.c� 81 zv�s
PAID
JUL -82015
Coo
CITY OF SC,Q'�i171A
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