|
J�„, .. Minnesot�l Deparbn.ent of Public Safety oft , ,�
<br /> �,?; '"�
<br /> � �.lcohol and Gambling Enforcement ^ ✓ =
<br /> ;,:, ;z
<br /> 444 Cedar Street,Suite 133 �'�:�. ' 'c��
<br /> �''���E�� St.Paul,MN 55101-5133 '��`3•'`'
<br /> 651-201-7507 •1fiY 651-282-6555 •Fax 651-297-5259
<br /> RENEV6'AL O�+'ILI�TJOR, WINE, GLUB OR 3.2% LICEl0iSE5
<br /> No license will be approved ot released until[he$20 Retailer ID Card fee is received by MN Liquor Conhrol�(3.2%Licenses exempt) .
<br /> Licensee: Please verify youi•license infoimation contained Uelow.Make coiz•ections if necessary and sign.City
<br /> Clerk/County Auditor should submit fllis si�ied renewal widz completed license and licensee liquor liability for the new license
<br /> period.City Clerl�/County Auditor are also required by M.S.340A,.404 S.3 to report Any license
<br /> cancellation.
<br /> s:`••• License Pei•iod Endin� 1.�r_';':',1.;'��'i,'•_t 1?!�.D# �•�'.,;'�~�
<br /> License Code �'" `-`�Y`�''�"'�' P
<br /> City/County where license approved. �-����'-'����'
<br /> Licensee Name 1...7�;r��,; j.���.^.� fa ra:l i`� ,�•I" r�Y'`a t'i r� �.i7�_.:�
<br /> Trade N�une
<br /> L��4�:���5� i t���,��f r.��� �.�f� r�1= ��r�u t'��
<br /> Licensed Location�ddress
<br /> ���'_�`i I'�1�:�r-•'��h f"i�'m �i'r'i.'��t
<br /> City,State.Zip Code
<br /> C_1 t'n n r�;,, Iwl I''�! a'��•�:;(:,,��.
<br /> B�uiness Phone
<br /> r:�r�._..._��.",%G:.;--:,;����J r�
<br /> I.ICENSE F'E�S: Off Sale$ On Sale$ S���Y�
<br /> �,�� r�t� t��„ 4'.>>_'.� �� �?�t?�
<br /> By signing this renewal flpplicafion,applicant ce�tifies that there has been na change in ownership on t�e a`bove named
<br /> Iicensee.For changes im ownershap,the licensee named above,or for new Gcensees,full apglications should be used.See
<br /> back of this application for f�artlaea�inPoruaation needed to complete tbis renewal.
<br /> A licflnt's si natnnre on this renewal c4nfirms the foll�win :Failure to re ort an of tl�e followin will result im fnn�s.
<br /> 1. Licensee confums ii has no interest whatsoever,duectly or induectiy in any olher liquor esca}�lishznents iu
<br /> Mivnesota.If so,�ive details on bacic of this applicltion.
<br /> 2. Licensee canfirius chat it 1�as never h1d�liquor license rejected by any city(township/county in die state of
<br /> " Miunesota.If ever rejected,plelse d ve details on the bacic of this renewal:then si�n below,
<br /> 3, Licensec confums that for die Past five years it has not h1d a liquor license revoked for�ny liquor law violltion
<br /> (state or local).If:�revocation h1s occarred,please give details on the Uacic of this renewal, then si�n below.
<br /> 4. Licensee confirms that d�uin�the plst five years it or its employees have not been cited for any civil or criininll
<br /> liquor law r-iolations.If violations have occ�ured;ple�se�ive details on Uacl:of this renewal, then sio below.
<br /> 5. Licensee confiims thflt duting the past license year,a suminons has nol been issued under die Liquor Liability
<br /> T�.w(Dra�n ShoP)MS ;�4QA.Rp?.Tf ye.e;attach a c�py of the summons, then siQn below.
<br /> 6. Licensee confii7n�thaC Woricers Compens�tioa iusurancc is in effect for the fu11 license period.
<br /> L,icer�see has�at�ach�d�liqasor Li��i!ity is�snnnatn�ce certi+�eate tha�co4respmc�ds with the Licea�se period in city/coaanty
<br /> whe�e 1ic��se is issaaed.�10'O,Ot➢0 in cash�a'securities or$100,dOd surety bond ciaay be sasbcnitte�l in leeaa m�liqee€��liabn6-
<br /> ity.(3.2�Io lit�aac�a-Iicsr�sQs are exempt q4'sales/ace iess;tl�an�0 ak on sale,vr$50,000 at of�'sale)
<br /> '� ' t'1 �,! � r` .
<br /> ,� � � � C .;� .r �� 'r,+
<br /> ��..i.�J � t iy� d._" .� � 'f .r� .
<br /> F,a�, • 'R, �� � t- .,..:. J : f. .� .., .i. '� -
<br /> (Si�na�ure certifies a111bove information to b�con•ect and license has been�pproved by city/county.) �
<br /> itv C'lerk/ .� nt�� Audit�r•SiCnstitte 1�1te -
<br /> �--
<br /> (Si�nattu�e certifies that rene«-11 of�liqu�r.wine or club license has becn lpproved by die city/county�s stated above.)
<br /> s1tntv ^,t rn�ev�onitu�e T��te �
<br /> Cuunty Board issued licetises or�y(�i�n�t!u- errifies licens e is eligible for licensej. �D� �
<br /> P� ' /S � . � f ZZ
<br /> (Signature cercilies licensee or associates h11�e at beeu cit2d�lurulg die pasc five yelrs fo�any sta[e/local liquoc law violcttions
<br /> (t,�i„u?lllcio'ill.Reporr�iolilL10T1�OP_b�tck, then si�n here. pS 9093-0�
<br /> �
<br />
|