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Minnewiu Depwiinent of Public Sifeiy <br />Akobol Mid GudbUng Enlbrntncnl <br />444 Cedar Street. Suite 133 <br />Si. Paul. NIN 53101.5133 <br />651 ^W>-697«^ • TTY 65I.282-6335 • FaJi 63I-2V7.3239 # <br />RENEWAL OF LIQUOR, WLNE, OR CLUB LICENSE <br />No »tn be jfTrmrJ « released ami the Reuiler CD C*d (ee n ivtmed by MN LK|oar ConBol <br />LiCtHf: Please serify your license infomution contained beloss. Make currectioos if necessary and sign. City <br />Cleti/County Audiior should submil this signed renessal wnh completed license and licensee liquor liability foi the new <br />license period. Clly Oerk/Ccnnly Audiior are also required by .\LS, 340A.404 S. J to report any license <br />caiKclIathNi. <br />License Code O^SL License Pcnod Ending lS/31 /SOOt ip# 7909 <br />Cily/Couniy where license appiosed. (ifliDftBft's name is changed, do nol use this form. Contact this office.) <br />Licensee Name Hi Liquor Inc. <br />Trade Name 12 Hi Liquor <br />Licensed Location address 2160 W Mayzata Blvd <br />City. State. Zip Code Long Lal<«» MN 55356 <br />Business Phone 1952) 2<»9-9358 <br />150.00LICENSE FEES: Off Sale S On Sale $Sunday $ <br />By signing this renestal application, applicant cerimes that there has been no change in ossnership on the abtise <br />named liceasee. For changes in ossnership. the licensee named abose. or for ness licensees, fuU applicaUons should <br />be used. See back of this application for further information needed to complete thb rencssal. <br />Applicant’s signalure on this renessal confirms the follossina: Faihsn? lo report anv of thf rtlllflfttlllf *lfll fTlllIt III flllfl <br />1 Lw-ensce confirms it has no interest wlulsocser. directly or indirectly in any other liquor csublishmcnu in <br />.Mmnesou. If so. give details on bock cf Oils appkcauon. <br />2. Lwenscc confirms that it has nescr hod a liquor license rejected by any ciiyAownship^couniy in the state of <br />.Mmnesou If eser rejected, please gise details on the back of this renewal, then sign below. <br />3. Licensee confirms that for the past fisc scars it has not hod a liquor license revoked for anv liquor law violation <br />(suie or local). If a resocation has oscurred. please gise details on the back of this renewai. then sign below <br />4. Licensee confirms that dunng the past five years it or its employees base not been cited for any civil or cnnunal <br />liquor law violations. If violations have occurred, please give d^ails on bock of this renewal, then sign below <br />3. Licensee confirms that dunng the past 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 Compensation insurance is in effect for the full license period. <br />Licensee has attached a liquor liablllly insurance certiflcale that correspoods with the license period in citv/counlv <br />where license b issued. $I00.(MN) in cash or securities or $100,000 surety bond mas be submitted In lieu of liquor ' <br />liability. <br />Licensee Signature <br />(Signalure certifies all abose infomution to be r'lnect and license has been approved by ciiy/couniy.) <br />City Oert/Coumy Auditor S-- nature _____________________________________ Date <br />0,^2^|,loo\ <br />(Signalure ceitifies that renewal of a liquor, wine or dub license has been approved by the city/;o<miy as slated above. <br />County Attorney Signature _________________________ |Vm.. <br />County Board issued licenses only (Signature certifies licensee b eligible for license). <br />Police/Sheriff Signature ________Dale <br />(Signalure ccrtjfies licensee or associates have not been cited during the past five years for any slate/local liquor law violations <br />(ctiminal/civil). Report violations on back, then sign here. <br />PS 9093 98