11-27-2006 Council Packet - Laserfiche WebLink

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,��°° Minnesota Deparrinent of Public Safety �F?HE:r, Q � �z. , , T J. � Alcohol and Gambling Enforcement ` '� a', -�' ' ..;z� 444 Cedar Street,Suite 133 d•:. -- _�:., Q�`°°^^^"�� St.Paul,MN 55101-5133 w''��issa:�?° 651-201-7507 •TTY 651-282-6555 •Fax 651-297-5259 RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES No license will be approved or released until the$20 Retailer ID Card fee is received by MN Liquor Control•(3.2%Licenses exempt) Licensee: Piease verify yoi.0 license infoimation contained below.Make con•ections if necessaiy and sib.City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period. City Clerk/County tSuditor are also required by M.S.340A.404 S.3 to report any license cancellation. License Code ��r��--��-�`�`1'=14-� License Period Ending 1 L:'�=�a ;��='�'��fD# ';'�':� City/County where license approved. '-��''�7-�t':� Licensee Name l,�:l p o[:I�'1 1 1 .I. C=Ci�!.i i i�t"�� :1.�_�.i.'t �.i i�_� Trade Name i 1�ij�:i f1� 1 �. 4.,��!.il';=Y-'t' �1�. �_!L, ��`g"�a � I � Licensed Location address ��(�� �� ��'�,�'i i;�i F::��;c:�i-f:i. :l :l I��:�.i �� City, State,Zip Code �,�� Q� c c_-;r- �_��.:(J i]r?,, �'��''�I ,��._f.=:)�. ��,��/ Business Phone :�r_.�'� . -- -- --•-� _._.%i�.;' :`.1•!...."`(•.:S•._'�•.�� LICENSE FEES� Off Sale$ On Sale$ Sunday$ 4'l�, I;'ik'I u''�.�'ii;ho 1�5E i c'4'��'�a 1��'E By signing this renewal applicafion;applicant certifies that there has been'no change in ownership on the above named licensee.For changes in ownership,the licensee named above,or for new licensees,full applications should be used.See back of this application for further information needed to complete this renewal. Apnlicant's signature on this renewal confirms the following:Failure to report anv of the following will result in fines. 1. Licensee confums it has no interest whatsoever,d'u�ectly or ind'u�ecfly in any other liquor establishments in Minnesota.If so,give details on back of this application. 2. Licensee confums that it has never had a liquor license rejected by any city/township/coimty in the state of Minnesota.If ever rejected,please give details on the back of this renewal, [hen sib below. 3. Licensee confums that for the past five years it has not had a liquor license revoked for any liquor law violation (state or local).If a revocation has occmTed,please give details on the back of this renewal, then sign below. 4. Licensee confums that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations.If violations have occiured,please give details on back of this renewal, then sign below. 5. Licensee confums that durin�the past license yeu•,a suznmons has not been issued under die Liquor Liability Law(Dram Shop)MS 340A.802.If yes,attach a copy of the summons, then sign below. 6. Licensee confiims that Workers Compensation insm�ance is in effect for the full license period. Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county where license is issued.$100,000 in cash or securities or$100,000 surety bond may be submitted in lieu of liquor liabil- ity.(3.2% liquor licenses are exempt if sales are less than$25,000 at on sale,or$50,000 at off sale). T 1l`PiICPP S�VTI'�r11TP �afe b�' (Signature certifies all above infoimation to be con•ect and license has been approved by city/county.) ,�',,�' �'1P�•k/r'ounty Auditor Si�rtature nate (Signatiu�e certifies that renewal of a liquor,wine or club license has been approved by the city/county as stated above.) rount� Attornev Ci�natm•e Date County Board issued licenses only(Si�nattu•e c tifies licensee is eliQ' 1 for license). - �- l� c �' (Signattu•e certifies licensee or associates hav not n cited durin�the past five years for any state/local liquor law violations (criminaUcivil).Report violations on back. then sign here. PS 9093-OS