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,E�� F�a Minnesota Departrnent of Public Safety �F:cH.- z,
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<br /> Alcohol and Gambling Enforcement � _
<br /> o,��, 444 Cedar Street,Suite 133 " __ �2
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<br /> E°�^�^�"�� St.Paul,MN 55101-5133 �y��(5g�J10'
<br /> 651-201-7507•TTY 651-282-6555 •Fax 651-297-5259
<br /> 1��+NEWAL OI+'LIQUOR, WINE, CLUB OR 3.2°Io LICENSES
<br /> No license will be approved or released untIl the$20 RetaIler ID Card fee is received by MN Liquor Contr�ol•(3.2°�o Licenses exempt)
<br /> Licensee: Please verify your license infoimation contained below.Make coirections if necessary and sign.City
<br /> Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license
<br /> period.City Clerk/County Auditor are also required by M.S.340A.404 S.3 to report any license
<br /> cancellation.
<br /> License Code I''���-:�,_.r��`��;`; License Period Ending 1�-�=���-�'�=�����D# � �-�"�'=
<br /> City/County where license approved. �l��"'-�'�"-`
<br /> Licensee Name �:ti)_�,l:�=�.i=._'. 1_:�,�J.T"i i�i�'S� �_'.1.i t�J �:i i���.
<br /> Trade Name
<br /> ►�i;::,,��,-��'}-,,. ijpr,.�'"!i_:p,:_ f":s,i�}�,
<br /> Licensed Location address f
<br /> �'�'I�_� �,5�.;i.'4�.:1,7.,c', J.�7,'��Cj �:��:•=7=
<br /> City, State,Zip Code
<br /> �.J.�'•l�,:1.'�..��.�i !�;f`+i Jt.f�._'�'_'a.l. .�
<br /> Business Phone
<br /> ��'=�' --�;'a .
<br /> ...J L,r "I'J�J� .}.J'�•F{'_�
<br /> LICENSE FEES: Off Sale$ On Sale$ Sunday$
<br /> G-�, C_��w� 'c`�.��o �`��'� �`4?14',0 �.��'�
<br /> By signing this renewal applicafion,applicant certifies that there has been no change in ownership on the above named
<br /> licensee.For changes in ownership,the licensee named above,or for new licensees,full applications should be used.See
<br /> back of this application for further information needed to complete this renewal.
<br /> Applicant's signature on this renewal confirms the following:Failure to reaort anv of the followin�will result in fines.
<br /> 1. Licensee confiims it has no interest whatsoever,di�ectly or iadirectly in any other liquor establishments in
<br /> Minnesota.If so,give details on back of this application.
<br /> 2. Licensee confums that it has never had a liquor license rejected by any city/township/county in the state of
<br /> Minnesota.If ever rejected,please give details on the back of this renewal,then sign below.
<br /> 3. Licensee confums that for the past five years it has not had a liquor license revoked for any liquor law violation
<br /> , (state or local).If a revocation has occ�ured,please give details on the back of this renewal, then sign below.
<br /> 4. Licensee confums diat dtuin�the past five years it or its employees have not been cited for any civil or criminal
<br /> liquor law violations.If violations have occtured,please give details on bacn of this renewal, then sign below.
<br /> 5. Licensee confums that during the past license year,a summons has not been issued under the Liquor Liability
<br /> Law(Dram Shop)MS 340A.802.If yes,attach a copy of the summons, then sign below.
<br /> 6. Licensee confums that Workers Compensation insurance is in effect for the fu111icense period.
<br /> Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county
<br /> where license is issued.$100,000 in cash or securities or$100,000 surety bond may be submitted in lieu of liquor liaUil-
<br /> ity.(3.2% liquor licenses are egempt if sales are less than$Z5,000 at on sale,or$50,000 at off'sale).
<br /> T +noncaa 5�.�� � i�ate �d `3�UG
<br /> (Signature certifies all above infoimation ro be coirect and license has been approved by city/county.)
<br /> �u�C'iP�•ti/r'ounty Auditor Sj.�mahtre i�ate
<br /> (Sib ature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above.)
<br /> C'ounty Attni�e��g7�at ire l�ate
<br /> County Board issued licenses only(Si�nat e certifies license e' 'ble for license).
<br /> �i<< d� /C
<br /> (Signatm�e certifies licensee or sociates av t been cited during the past five years for any state/local liq or law violations
<br /> (criminaUcivil).Repor[violations on back, th sign here.
<br /> PS 9093-OS
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