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1 <br />Minnesota Depanment of Public Safety <br />Alculiul and Gambliii;i: Eiiforccnicnt <br />444 Cedar Siieet. Smic 133 <br />Si Paul. MN S510I-5133 <br />651-296-6979 • TrV 65l-2S2-6'55 • I a\ 651 297-5;59 <br />.-i.* <br />W-' .e /' <br />RKNKWAL OF UQrOR, WINE, OR CLEH EICENSE <br />No license vMil he ;ipp:n\cd or released until Uie S’O Retailer ID Card fee is rcccr.a! by MN I iquc»f Control <br />IJccnsct*. Please verify your license information contained below. Make collections if* necessary and sign. City <br />rierk/Count) Auditor slioiild submit this signed renewal with completed license and Iicen.see liquor lir i'ilily for the new <br />license j ericKl Ci!y ClerL'Couiity Auditor arc also required by M.S. 340A.401 S. 3 to report any license <br />cancelhitioii. <br />License Code License Period Emlina <br />Ciiy/Couiity where license approved. ‘ <br />rniintyo Tlphi Jnr. <br />Pn'.'nLr^»«h <br />pP.t?. ir.1 <br />nv'onci. Mfx! <br />Licensee Name <br />Trade Name <br />Licensed l.ocation tuMress <br />City. State. Zip Cixlc <br />Husmess Phone <br />u J 1 <br />UCKySli FFKS: Off Sale $On Sale $Sundav $iTi:'*! j 7»C <br />By signing this renewal application, applicant certines that there has been no change in ownership on the aimve <br />named licensee. Foi changes in ownership, the licensee named above, or for new licensees, full ap|)Iications slioiihl <br />he used. See hack of this application tor furtlur iiirormation needed to complete this renewal. <br />.Afiplicant\ sij^iiaLnre on this rejieual coiifiriiis the foUirwing: Faihire jiMcprii t any of the hdhrwing wUI rcMJii^^ njus. <br />1. Licensee confirms it has no interest whatsoever, directly oi iiulncctly in any ollici I k|uui establtshmeiits m <br />Minnesota. If so. give details on hack of this application. <br />2. Licensee confirms that it has never had a liquor license iejected by any C!t>7t'»wnship'c(Hinty in the Slate of <br />Minnesoti. It cu*r rejected, please give details on the back of this renewal, then sign Indow. <br />3. Licensee confirms that for the past In • ycais it has not had a liquor license rcsoked for any lii|uor law violation <br />(stale Cl local). If a leuK'alion has ixcuricd. please give details on the back of this renewal, then sign below. <br />4. Licensee conftims that dunng the past fne years it or its employees have not Iven cited for any civil or uiminal <br />ii<|uor law viol.iiions If \iolalions have occuried. please gi\e details on back of thus renewal, llicn sign i eiow. <br />5. Licensee confirms that during the past license yeai. a summons has not been issued under the Liquor Liability <br />Law (Dram .Shop) MS 3 R.) \ 802. If yes. ati iJi a copy of the summons, then sign below. <br />6 Licensee conlirins that Workers Compen.vation msuiance is in effect for the full licen.se jxniod <br />I imiscc has attached a licpifir li.ihility insurance cn liticate that corresponds with the license period in cit> Voiinty <br />where license is issued. SIOO,0(K) in cash or seeiirities ui $1()0,0U() surety hoiid may he suhiiiitteci in lieu of liquor <br />liability. ^ <br />. - // /5 Qn ‘Licensee Mgnaln ic _ /// ____________________________________Date /^ •'c^d ^ <br />(Signature certifies at above inf ormation to be correct and license has been approved by city/county.) <br />Cil' Cleik/Couniv Auditor Sicnaluie Dale <br />(Signature certifies that lenewal of a liquor, wine or cluh license ha.s been approved by the city/county as staled above ) <br />Counts .Aiioinev Signature D.ue <br />County I3o.ird iss cd licenses only (Signature certifies licensee is eligible lor licenser <br />rohee/Shenff Signaiiiie Dale <br />(Signatiue ccnifies licensee or associates have not been cited dunng the past five years for anv suic/local liquor law violations <br />(ciimmaLcivil). Report violations on back, then sign here. <br />PS 90»23 9S <br />j