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^ - <br />i <br />f' <br />r •’ p <br />k; <br />'1 . <br />• <br />'U .->^1 <br />Minnesota Depanment of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar Street. Suite 133 <br />St. Paul, MN 55101-5133 <br />651-296-6979 • TTY 651-282-6555 • Fax 651-297-5259 <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />No license will be approved or released until the S20 Retailer ID Card fee is received by NIN Liquor Control <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new <br />license period. City Clerk/Couiity Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />cancellation. <br />License Code <br />City/Counly where license approved □ r o n o <br />License Period Ending ^S/31 /2000 ID# 7909 <br />Licensee Name 12 Hi Liquor Inc. <br />Trade Name 12 Hi Liquor <br />Licensed Location address 2160 W Ulayzata Blvd <br />City. State. Zip Code Long Lake, MN 55356 <br />Business Phone ^ ^ 12) 249-9358 <br />LICENSE FEES: Off SaleS 150.00 On Sale $Sunday S <br />By signing this renewal application, applicant certifies that there has been no change in ownership on the above named <br />licensee. For changes in ownership, the licensee named above, or for new licensees, full applications should be used. <br />See back of this application for further information needed to complete this renewal. <br />ApnIicanCs sli^nature on this renewal eonfimw the following; Failure to report anv of the following will result in lines. <br />1.Licensee confirms it has no interest whatsoever, directly or indirectly in any other liquor establishments in <br />Minnesota. If so. give details on back of this application. <br />2.Licensee confirms that it has never had a liquor license rejected by any city/townsh.p/county in the state of <br />Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. <br />3.Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation <br />(state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. <br />4.Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal <br />liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below. <br />5.Licensee confirms that during 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 liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor <br />liability. <br />Licensee Signature Date <br />(Signature certifies all above information to be correct and license has been approved by city/county.) <br />City Clerk/County Auditor Signature______________ __________________ Date <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above. <br />County Attorney Signanire __________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 during the past five years for any state/local liquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br />PS 9093-98