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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite i33 <br />St. Paul. MN 55101-5133 <br />651 -296-6979 • TTY 651 -282-6555 • Fxx 651 -297-5259 <br />w <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />No license will be approved or released until the $20 Retailer ID Card fee is received by MN Liquor Control <br />Licensee : Please verify your license information containt. 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/County Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />cancellation. <br />License Code ^CLDNSS <br />City/Countv where license approved D c o n o <br />Licen«.Name Country Club Inc. <br />TradeName Wayzata Country Club <br />License Period Ending 1D<> ^ ^ <br />Licensed Location address ^00 Wayzata Blvd/Box 151 <br />City. State. Zip Code MN 55391 <br />Business Phoned 612) 473-88A6 <br />LICENSE FEES: Off SaleS On Sale $100.00 Sunday $200.00 <br />By signing this renewal application, applicant r.ertifies that there has been no change in ownershif on the above named <br />licensee. For changes in ownership, the Iicen.«ee 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 />Applicant ’s signature on this renewal confirms the following: Failure to report anv of the following will result in fines. <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 hxs never had a liquor license rejected by any city/township/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 confinru' 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 licenie period. <br />Licensee has attached a liquor liability insurance certificate that corresponds with the license period In city/county <br />where license b issued. $100,000 in cash or scc^ties or $100,000 surety bond may be subn:itted in lieu of liquor <br />Uability. <br />Licensee Signature <br />(Signature certifies aii above information to be coue^nd license has been approved by city/county.) <br />Citv Cierk/County Auditor Signature _________________ <br />Date <br />(Signature certifies that renew al of a liquor, w ine or club license has been approved by the city/county as stated above. <br />County Attorney Signature __________________________________________________Date_____________ <br />County Board issued licenses only (Signature certifies licensee is eligible for license). <br />Police/Sheriff Signature ____________________________________________Date <br />(Signature certifies Ucensee 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.PS 909?-9o <br />■.-.mH.'V'..1 •-...<•!*•'*■■r w MulI/VIMAA ivjmfllBKia