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r <br />Minnesota Department of Pubrvr 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 MN Liquor Control <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Cierk/County Auditor should submit this signed renewal with .'ompleted license and licensee liquor liability for the new <br />license period. City Clerk/County Auditor are also required by Sl.S. 340.\.404 S. 3 to report any license <br />cancellation. <br />License Code MCLONSL <br />City/County where license approved U r o n o <br />VJoodhill Country Club Inc.Licensee Name ' <br />Trade Name Woodhill Country Club <br />License Period Ending ID# <br />LicensedLocaUonaddress Woodhill Nd <br />City. Sute, Zip Code 55391 <br />Business Phone 2)473-7333 <br />I.ICENSE FEES: Off .SrleS On Sale S 100.00 Sunday S <br />By signing this renewal application, applicant certifies that there has been no change in ow nership 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 />Applicant ’s signature on this renewal confirms the following: Failure to report anv of the following will result In fines. <br />1.Licensee confirms u i* *. no interest w hatsoever. directly or indirectly in any other liquor establishments in <br />Minnesota. If so. gi.e details on back of this application. <br />2.Licensee confirms that it has 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 />(slate or local) If a revocation has occurred, please give details on the back of this renewal, then sign below. <br />4.Licensee confirms tiiat during the past five years it or its employees have not been cited for any civil or criminal <br />liquor raw 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 (D. m Shop) MS 34CA.802. If yes. attach a copy of the summons, then sign below. <br />6.Licensee confiims 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 />Uability. <br />Licensee Signature '’Vu a aw Date <br />(Signature certifies all above information to be correct and license has been approved by*city/county.) <br />City ClorkATounty Auditor Signature Date <br />(Signature certifies that renewal of a liquor, w ine or club license has been approved by the ciiy/c junty as stated above. <br />County Anomty Signature____________________________________Date ____________ <br />County Board issued licenses only (Signature cenifies licensee i.. eligible for license). <br />PoUce/Sheriff Signature Date <br />(Signature certifies licensee or associates have not been cited during the past five years for any staie/Iocal liquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br />i <br />1 <br />f