11-27-2006 Council Packet - Laserfiche WebLink

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,� °^� Minnesota Department of Public Safety otTHE r,r amTv: ' �`�o Alcohol and Gambling Enforcement " � <:` u� 444 Cedar Street,Suite 133 a;- -� -;�2 ��Epi��f5�4r St.Paul,MN 55101-5133 �y�:��g:�v°� 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$20 Retailer ID Cu'd fee is received by MN Liquor Con[�oL•(3.2%Licenses exempt)' Licensee: Please verify youi•license infoimafion contained below.Make con•ections if necessary and sign.City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period.City Clerk/County Auditor are also required by M.S.340A.404 S.3 to report any license cancellation. License Code W� �='�t`�`=�� License Period Ending 1�='��•-`�f�`+_'��f��# �"�=�'�'�` City/County where license approved. !'�' '=1+�+'=� Licensee Name C:i t�.r ��'F' l..i�'�ta;-i« Trade Name �t'��i�� i't t�� l i� fa'Q�. '� Licensed Location address ��; Or�o n a ��r-�cl-��y r�� f;ci c City, State,Zip Code ��.,t3 il��y �.T.�''v �`"1•"''�i Business Phone r'-1�';`� L �' �",-,t�'1L ..�.�.— t(.r-- 1r f LICENSE FEES: Off Sale$ On Sale$ Sunday$ �'�a t� 1 i:'1 I?t o tt�i I�i C�'1, E%i�,'1 By signing this renewal applica�ion,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. Anvlicant's signature on this renewal confirms the following:Failure to report anv of the foliowine will resuit in nnes. --____ ___ 1. Licensee confums it has no interest whatsoever,directly or indirectly in any other liquor establishments in 11�innesota:I so�give- eta s on ac o - is app ca on. __ 2. Licensee confums that it has never had a liquor license rejected by any city/township/county in the state of Minnesota.If ever rejected,please give details on the back of this renewal,then sign 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 occun•ed,please d ve 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 crinunal liquor law violations.If violations have occuned,please give cletails on Uack oi dlis renewal,ihen sign below. 5. Licensee confums that during the past license year,a suuunons has not been issued under the Liquor Liability Law(Dram Shop)MS 340A.802.If yes,attach a copy of the summons,then sign below. 6. Licensee confums that Workers Compensation insurance 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.(3Z% liquor licenses are exempt if sales are less than$25,000 at on sale,or$50,000 at off sale). i:�Pn�PP SianatLre i�ate (Sibnature certifies all above information to be coirect and license has been approved by city/county.) �,y('ler�/rountTAuditor Signatnre i�ate (Signahue certifies that renewal of a liquor,wine or club license has been approved by the city/county as stated ahove.) C'ount�Attorne�,S.itm,ar„rP Date County Board issued licenses only(Signature certifies lice see is eligible for license). ///7Z /G� (Signattue certifies licensee or associat s e not been cited during the past five years for any state/local liquor law violations fcriminallcivil).Report violations on back, then sign here. PS 9093-OS