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MinneioUi Dcpiutmciit uf Public Safety <br />Alcohol mihI Gumblliife Eiirorccniciil <br />444 Cednr Stircl, Suite 133 <br />St. Paul. MN 5.5I0I-5I13 <br />fiM ?.% 697‘3 • n Y 6JSI 282-65.S5 • b*nx 6!SI 297 ViV; <br />KKNEWAL OK LIQUOR, WINE, OR CIAJB LICENSE <br />No licenw will lie apf>riived or leleaiecJ iiniil llie $20 Kclaiirr IIJ Card fee is received by MN [.iqiinf Cniilrol <br />LiccilSSfi: Please verify your license iiifonnollon contained below. Make coircctions if nccc.ssary and siKn. City <br />CIcik/Counly Auditor should submit this sicned lenewol with completed license mid licensee licjuor liability for the new <br />license |>eiioil. City Clerk/County Auditor arc also m|iiircd by M.S. 340A.4(M S. 3 lu report miy Hmise <br />CHPccllalion. <br />_____________________License Period nndin>» <br />(!lly/County where license uppiovcd. ’^ ***^'’ <br />License Code ."•p..-* I <br />Licensee Name <br />TVnde Name <br />Licensed Location address <br />City, State, Zip Code <br />Business Plionc <br />rir.rriifi Hill Oi»l f Plnh T»*r'. <br />^nrimi Mill Hn | f Di.iS <br />7pr. r.+ h M <br />llmnn. t.|M <br />LlCENSOEESoff Sale $i vi. m»i <br />On Sale $ <br />|7|»^ <br />Sunday $ <br />\^\7i <br />By si(*nliiK this renewal upplkatluiu U|i|iliniiil i'erlilles that there lia.s Irern mi rhiin{*e in ownership on the siliovr <br />named llceitsee. For elian|»rs In ownership* the licensee named alrovc* or fur new licensees, full appliculioiis should <br />lie used. »Sec back of this application for further infoniintioti iieefled to rompletr this renewal. <br />1. Licciuscc confiiins it has no interest whutsocvci. dii^lly or indiicclly in any other iMpior rMablishinniIs in <br />Minnesota. II so, give details on back uf this application. <br />2. I .icciiscc coiifiims that it has never had a li(|uoi license irjecfed by any cify/fownship/rminty in the stale of <br />Minnesota. If ever rejected, plca.se give details on tire hack of this renewal, llicii sign Ixrlow. <br />3. Licensee confirms that for the past five yeais it has not luid a Iii|uor liccn.se icvokcd foi any liquor law violation <br />(.siiiic or local). If a revocation has occnnctl. please give details on Ihc back of this renewal, then sign below. <br />4. Liccn.scc confums that dining the past five yeais it or its employees have not liecn cited for any civil nr criminal <br />liquor law violuliuiis. If viulatiucis have occuiicd, please give details on back of this lencwul, then sign below. <br />5. Licensee confirms that during the pn.st license year, a simuiions has not been issued under llic Liquor ’ Liability <br />I.41W (Drum ,Sbop) MS 340A.802 If yes. attach a copy of tlic summon.s. then sign liclow <br />6. Licensee cuiifirms that Workers Cumpcusaliun insuiuncc is in elfcct for the full license (>eiiod. <br />Liccii.srt! has uthiclicHl ii liipior Ihilillity iiisiirunct* cei tinrati* that cortYspmids with the license perind In clfy/county <br />wlwn* Uceiisf b issued. $100,000 hi cash ur .u*curUies or $100,000 surely bond may Ire siiiiiiiitted in lieu of licptor <br />llahillfy. . 1 <br />14CCIISCC Signature ^ <br />(Signnim« ccnifies all nlwivc information to be correct and license has been approved by city/counly.) <br />City Clak/Coiint y Auditew Signat uie __ Date <br />(Signntuir ccififies that r.:ncwal of a liquor, wine or club license has been upptovcJ by the city/couniy aa stated alnive.) <br />County Attorney Signature pate <br />C'ounly Bomd issued licenses only (Signatuie ccitifies licensee is eligible for liccn.se). <br />|-olicc/^>hcrifl Signatu re <br />(Sigiuituic ccitifics licensee ui assc^^tes have nut Irccii cited dining tfic |ml five years for any statc/local liquor law vtolntions <br />(crirninal/civil). Report violations on back, then sign here. <br />PS 9093 9H <br />Jlate <br />Dale