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����^ Minnesota Department of Public Safety oF..�+..r,
<br /> �' "'�
<br /> � � Alcohol and Gambling Enforcement �P ':_
<br /> 444 Cedar Street,Suite 133 "'a:� � '
<br /> -�
<br /> sj'�°F°��"�°' St.Paul,MN 55101-5133 �H�.;xsa:d''
<br /> 651-201-7507•TTY 651-282-6555 •Fax 651-297-5259
<br /> RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES
<br /> No license will be approved or released until the$20 Retailer ID Card fee is received by MN Liquor Control•(3.2%Liceuses exempt)
<br /> Licensee:Please verify your license information contained below.Make coirections if necessary and sign.City
<br /> Clerk/County Auditor should submit this sib ed renewal with completed license and licensee liquor liability for the new license
<br /> period.City Clerk/County Auditor are aiso required by M.S.340A.404 S.3 to report any license
<br /> cancellation.
<br /> License Code -'-������E•�- License Period Ending ��=������ '��!���D# '=�'=�`a'i
<br /> City/County where license approved. �-7�''->a�"�'
<br /> LicenseeName i�,l�,.'•�_,.r'r"� L_��:,�.t[;r:� Ti-i���r
<br /> Trade Name -
<br /> Licensed Location address
<br /> ,=,,'-F�''� `��Cl!?Y-•�1 1.!;:� L�t'-';�f-�i_I F}.�,;;- =- `;,
<br /> City, State,Zip Code
<br /> {"`:;?,t,+_7,F'�1''`Y, !'�I±''•1 •`��•`._�..°�`�c.
<br /> Business Phone
<br /> ^�;�'��F"T 1.—•�r;��lta�t
<br /> LICENSE FEES: Off Sale� On Sale$ Sunday$
<br /> � �4:�� 4,h!�t 4••'�� l%.'�4.� �7�u 4'�4:�
<br /> By signing this renewal application,app�icant 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 /> Apalicant's signature on this rene�i�al confirms the following:Failure to repflrt any of the following will result in fines.
<br /> 1. Licensee confu-ms it has no interest whatsoever, d'u•ectly or induectly 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 si�n 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 occuired,please give details on the back of this renewal,then sibn below.
<br /> 4. Licensee confums that d�uing the past five years it or its employees have not been cited for any civil or cruninal
<br /> liquor law violations.If violations have occun•ed,please give detaiis on back of this renewal,then sio below.
<br /> 5. Licensee confiims that during flie past license year,a summons has not been issued under the Liquor Liability
<br /> Law(Dram Shop)MS 340A.802.If yes,att�lch a copy of the sununons, then sign below.
<br /> 6. Licensee confums that Workers Compensation insurance is in effect for the full license period.
<br /> Licensee has attachecl a liquor liability insurance certificate that corresponds with the license period in city/county
<br /> where license is issued.$100,000 in cash q,r securities or$100,000 surety bond may be submitted in lieu of liquor liabil-
<br /> ity.(3.2% liquon c�enses are exempt,.i£�„es are less than$25,000 at on sale,or$50,000 at off sale).
<br /> a,� v ,.
<br /> -:.� .�.,, . /1
<br /> T il�P1lCPP�� C r , .�. 11� r{ � nate "� ���/����
<br /> � _"" '� .. .v _�,. '
<br /> (Si�nature certifies all above information to be con•ect and`li,cense has been approved by city/county.)
<br /> �.,
<br /> �it�C'lerk/ oimtv Auditrn•Ci�nature .� Date
<br /> (Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above.)
<br /> (�nnntv Attror�av�`jon�Y�ll'P nate
<br /> County Board issued licenses oi�ly(Si�natlue ertifies licensee is eliQ' le for license).
<br /> 1. Q � ii � 6G
<br /> (Si�nat�ue cer[ifies licensee or associates have no en cited durin�the past five years for any state/Iocal liquor law violalions
<br /> (criminallcivil).Report violations on b�ck,then si�n here.
<br /> PS 909�-OS
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