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©Muinewu Dqnnibem of PubUc Safety <br />AI coImI and GamMint Enforcvamil <br />444 Cedar Street. Suite 133 <br />Si. Paul. MN 55101-3133 <br />631-29&-W79 • TTY 631-282-6335 • Fax 631-297-3239 <br />RENEWAL OF LIQUOR, WINE. OR CLUB LICENSE <br />No bcrmc «nll be approved or rrleatcd uaul ihe 520 Rctatkf ID Card fee it iccn«cd by MN LM|iiat Cooiral <br />HcwMce: Pleate %enfy your Ucense informatioo contained below. Make corrccuoiu if necesury and tign. City <br />Cterl/Couniy Auditor ihould submit this signed renewal with completed license and licensee liquor liability for the newr <br />license period. City Clerk/Counly Auditor art also required by M.S. 340A.404 S. 3 to report any license <br />canccUalloii. <br />License Code MCL0NS5 License Period Ending 15/31/5001 ID# 1196 <br />City/Couniy where license approsed. (ItfllCMM's name is changed, do nor use this form. Contact this oRke.) <br />Licensee Name Country Club Inc. <br />Trade Nome Mayzata Country Club <br />Licensed LocaUon address 200 Uayzata Blvd/BoK 151 <br />City. State. Zip Code Orono, MN 55391 <br />Business Phone 1955) 473-8046 <br />100.00 . 500.00I irrvSE rFF-S off Sale S On Sale $Sunday $ <br />By signing this renewal application, applicant certifies that there has been no change in ownership on the abose <br />named licensee. For changes in ownership, tlie licensee named abose. or for new licensees, full applications should <br />be used. Sec bock of this applicalion for further Information needed to compleir Ihb renewal. <br />Appitcanfs signature oa this renewal cooBrms the folkiwloa: FaHure to report ans of Ihe fallowing will result in llnei. <br />1. Licensee confirms it has i»3 uueTest whatsoeser. directly or indirectly in any other liquor establishments in <br />Minnesota. If «o. give details on back of this application. <br />2. Licenice confirms that it has never had a liquor license rejected by any city/township/county in the state of <br />Muinevoia. If esei rejected, please gise details on the back of this tencwol. then sign below. <br />3. Licensee confirms that for the past fise years it has not had a liquor license revoked for any liquor law violation <br />(state or local) If a revocaiiun has occuned. please give deiailv on the back of this renewal, then sign below. <br />4. Licensee confirms that during the past five years it or lU employees have not been cited for any civil or criminal <br />liquor law violationv. If violations base occurred, please give details on back of this renewal, then sign below. <br />5. Licensee confirms that during the post license year, a summons has not been issued under the Liquor Liability <br />Law (Dram Shop) MS 340A 802. If yes. attach a copy of the summons, then sign below. <br />6. Licensee confirms that Workers Compensauon insurance is in effect for the full license period <br />Licensee has attached a liquor liabt'4t) tOturance certificate that corresponds with the license period In rily/county <br />where license is issued. $100,000 « ash or purities or $100,000 surels bond mas be submilled In lieu of liquor <br />liubilily. <br />□on ♦ash or^urlllr <br />Date /O/^g/qyLicensee Signanire ____________________________________________________________ <br />(Signature cenifies all abose information to be and license has been approved by city/county.i <br />City Oerk/Tounty Auditor Signature Date___________________ <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/couniy as stated above. <br />County Aitomey Signature _______ Date___________________ <br />County Board issued licenses only (Signature cenifies licensee is eligible for license). <br />Police/Sheriff Signature _______________________________________________________Date___________________ <br />(Signature certifies licensee or associates have not been cited durinf the past five yean for any siaie/local liquor law violaiiOQS <br />(chmiiul/cisil). Report violaticas oa back, then sign heie. <br />PS 9093-98