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,�z�°P ,, Minnesota Department of Public Safety pfTxE�ST,'
<br /> FTy.' , ..�,
<br /> Alcohol and Gambling Enforcement :" � '�.
<br /> 444 Cedar Street,Suite 133 "`_ -� �'
<br /> ' ��'Ew,.n��' �'�'y�.......��j.o
<br /> St.Paul,MN 55101-5133 +�AS
<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$20 Retailer ID Card fee is received by MN Liquor Control•(3.2%Licenses esempt)
<br /> Licensee:Please verify your license infoimation contained below.Make con�ections if necessary and sign.City
<br /> Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license
<br /> period.City Clcrk/County Auditor are also required by M.S.340A.404 S.3 to report any license
<br /> cancellation.
<br /> ���-� ''' _��:f. ;`�.�;�i!��j�# :!.�3='`��3=�
<br /> License Code �'° �=�-� �-'�•- License Period Ending ��'�����
<br /> City/County where license approved. �—����'-'a��"
<br /> L1C0RSC0 Nr11710 }�a'��-1.C�E��_l Y' C.'.,�.Y'��r 1:�F_' %_.,%1 t�:.%Y'�• �.Tl!_:a
<br /> Trade Name
<br /> �•�j1 fJ��..� � ��'e ._.i�9 _. �'1��.�. .1.1'�.-1,i�
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<br /> Licensed Location address
<br /> '' y't�� ��h u;.[:f�'!��,a_r.l R t:i
<br /> c:�f-�.. ,
<br /> City, State,Zip Code
<br /> 1_j•'i1 r.t;i ii; . cr_•-•1�;�
<br /> i t i I= •_J•_l.::i •t_
<br /> Business Phone
<br /> �...� • -i��-�r._r� .
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<br /> LICF'NSF FEES: Off_Sale$ On Sale$ Sunday$
<br /> c1!��,. �'iL'{ 4'!� �'�� 7, 4 1'f
<br /> By signing this renewal applica�ion,ap"plicant certifies that there has beeu no c�ange in ownership on t�tie a�ove 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 /> Aaalicant's si�nature on this renewal confirms the following:Failure to reaort anv of the followin�will result in fines.
<br /> 1. Licensee confums it nas no interesi wnatsoever,directiy or ind'uectiy in any oL'ner liquor estabiisrunents iu
<br /> Minnesota.If so,give details on back of this application.
<br /> 2. Licensee confuYns fliat it has never had a liquor license rejected by any city/township/county in the state of
<br /> Minnesota.If ever rejected,please�ive 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 /> (st�lte or local).If a revocation has occiured,please cive details on the back of this renewal,then sign below.
<br /> 4. Licensee confums that diu•in�the past five years it or its employees have not been cited for any civil or criminal
<br /> liquor law violations.If violations have occun-ed,please give details on back of this renewal, then sign below.
<br /> 5. Licensee confinns that during the past license year,a stwunons has not been issued under the Liquor Liability
<br /> T.aw(D,�a•,, Shopl M,C 340A.802.If yes,attach a cony of the suuunons.then si�-n below.
<br /> 6. Licensee confiims that Workers Compensation insiu•ance is in effect for the full license 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 tiabi9-
<br /> ity.(3.2% liquor licenses are exempt if sales are less than$25,000 at on sale,or$50,000 at off sale).
<br /> , �_� , �/ ,
<br /> � yL� � `�- � .(', , I / �G= D G�
<br /> (Sionature certifies all ab Je�iufoimation to be con�ect and license has been approved by city/county.)
<br /> ��('lerlc/C'otmtv Anciit�r Cj,��nature l�ate
<br /> (Signatiu�e certifies that renewal of a liquor,wine or club license has been approved by the city/county as stated above.)
<br /> r,. .,r<, �rr� P.�Si�natnre 1�ate
<br /> Cotmty Board issued licenses oi�ly(Signat certifies licensee is ig� le for license).
<br /> 1' O� �/ D
<br /> (Si�nature certifies licensee or associates h ve o been cited dm�ing the past five years for any state/local l'quor la violations
<br /> (criminaUcivil).Report violations on back. flie s�en here.
<br /> PS 9093-OS
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