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Minnesota Dep iiiincni of I*iiblic Safety <br />Akoliul ami fJaintiting linrorccmcnt <br />414 Odi! Sncci. Sniie I <br />Si Paul. MN SMOI -5131 <br />foi-r)r)4>*;v9 • ri Y (>5i 2s:-fo.s.s . Pax 6si-:o7 5:50 <br />KKNKWAI. OF U(.HOK. WIN! . OK C l.l'U MCKNSK <br />A- <br />-------- %/V-O <br />V»* iitniNT uill f»c ap|ti(uec! *m irK*a'c4 uiiiil ihr i2n kciailcr ilJ ( .u<l (ci* is iricivt.l !•> MN I Cunliol <br />J.irriisoc* Pirate verify ynur license inloimaiion coniainc4 Ih'Io.w Make collections if iiecesvai) aiul sicn. City <br />CIviki'C’ouiay Auiliior slunilil sulnnii ilii » si* iiiil lencual with coinpK ietl Ikcnve ami Iicena ’c Iii|m>i liability fio the new <br />license [H iioil P?ity i’leriv/f’ounty AucJitnr arc also re(|iiiml hv ,M.S. 340 \.404 S. 3 lo iTport any licen»^c <br />eaiitell.ilioii. <br />I i*uense Coile Mr* <br />Cit>/County where license approved. ^ <br />l^nr.rl’i 1 I T f‘' ‘ ‘I* P'* t* ’• <br />I4r. nr!hil) PnMrf.'i# P^!4> <br />r.lTuTl ‘Jr.r.Hhill pr <br />To ro.i Otri v.Q! <br />l.iccrisc IViioil L dinp___1 / ? ^ /* »‘^*«‘** _______ <br />lacensee Name <br />Tiaile Name <br />I iceiiscd I (valion ailJicsS <br />( ity. Si ale. /ip (*n<le <br />Piismess Phone <br />I.ICI.NSP; I PKS: Olf Sale $ <br />I*' <br />On Sale $Suiidav S <br />3i?t -V2* <br />lly sipnin;* this mieual appitcalioii, applicant certilies Ilia; then* has hmi no chain^c in ouitcr^bip on the alio\r <br />iiaiiicti licensee. P'or clianues in oMiieisliip, the lii eiisee nanieil aho\e. or for ii« u liieiisees. full ap|diralioiis should <br />he used. See hack of this •ipplicaliuii for fui llici liifoi ination needed to coiU|)lcte tliis l eiicuak <br />Applicant *s simiatuie on this mu ual conriiiio the folloxHii;;: iniihiie to report aii> of the folloxtiu^ uil| lesiilt in fliie^. <br />1 I.Kcnsee conliinis il has no inleiest what'^mnei. diicclK »>! iiulnectl) in any oilici lu|mn cst.iblislimcht‘. in <br />Minnesota, it so. pive tiel.iils on back tin. applii ati*m <br />2 I icciisee conriiius that it has nexei had a liipi»»i hecu^.- lejivted by any city/toxMisliipVtxnnly in the slate ol <br />Minnesota It e\ei ri’jecleil. please eixe details on the baek ol this renexval. then sijpi Ivloxx. <br />3. laeeiisec conlmii^ (hat loi the past fixe xeais il hiis not h*i»l a lujiu*! h» eiise lexoked foi .lux lupioi law violation <br />(stall or hkah If i leuxcalo a has iH.kuiied. please p\c detasU xxn the back »4 tins leiiexxal. then sien Ivloxx <br />4 I icensee contums that diinn;* the past lixc yeais it oi its employees have not Iven vile ! toi anx vivil oi criminil <br />lu|iiot law xiol.ilu'iis It Molalioiis haxe »ki lined, please eixe icl..j|s on ba»>k o\ this leiiexxal. then Men Ivloxx <br />y. I leensee coiiliim.s that durme the past liccn c‘ seat, a summons ha.s iu*l Iven issued und.r the I lipioi I lability <br />14IXV (Diain Shopi MS .t Ml \ M ’ It yes. .iti.uh a cops t»f the summons, then sieii below. <br />6 I icciisee coiiliims tli.il Woikeis 1 ompens.imm msuiance is in ellei 1 loi the lull license jviuhI <br />I tcciisee lias attached a liipii*^^ Italnlity itisnrance certilic.ite that corresponds xxiili the license period in city/eonnlx <br />xxlicic lit I’ll e is issued. >IOO.oOO in cash or sccnrilies or $10(UHH) surety Iioiid ni.iy he siihiiiilletl in lit 11 of liipioc <br />liahilitx. <br />I iceiisee Su’iuiuic a A <br />tSi^n.iUiie icitilies .ill .ibo\e inlonn.iiioii to Iv collect and Ikciise has tven appiovnl by ciiy/coiinly > <br />i*ilx Cleik/C oiinlx .Aiidilo: Sieiiatme Ikite <br />(.Sienatuie iciidics th.il icncw.il ol a liquor, wine or club iKcnse has bciii appuxxed by the iiiy/i*>unt> as stated aKsxe I <br />« oiintx Aiioiiiex Sten.iiuie Pate <br />C» unt> Hi>.ud i>Mietl lu cases only (Sign.itiiie cenitics licensee is eligible tor licen.sc) <br />Pi>lice/Mienll SiiMi.iluie ___i')ate <br />tSignaiuu' ceitilu s licensee or assiKiatcs have not neen cited duiing the past five years fx^r any suie.lival lK|ux»r law violations <br />(i iiiiuiial 11\il) ke(HMt violations on hack, then Mgn heie <br />PS OS