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5^ <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />■U4 Cedar St.. Suite 133 <br />St. Paul.NLN 55101-5133 <br />6i:-296-(Si:'0 • TTY612-23:-6555 • F.AX 612-297-5259 <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />No licsnie uiU be approved or released ur.u! Lbe 520 Retailer ID Card fee is received by SIN Liquor Cocrot <br />Licensee: Please verify your license informanon contained below. Make corrections if necessary and sign. City <br />Clcrk/'County .Auditor should submit this signed renev^al with completed license and licensee liquor liability for the new <br />license period. City Clerk/County .Auditor arc also required by M.S. 340.A.404 S. 3 to report any license <br />cancellation. <br />License Code __QE License Period Ending ID ».I n D5 <br />Citv/Countv where license approved □ r o r. o <br />Licensee Name 12 Hi Liquor Inc. <br />Trade Name 12 Hi Liquor <br />Licensed Location address 2120 L <br />City. State. Zip Code Long Lake, <br />Business Phone; £12) 2A3-92S3 <br />• » errr Z <br />I II « ^ ^ ^ <br />LICENSE FEES: Off Sale S 150. C On Sale S Sundav S <br />By signing this renewal application, applicant certifies that there has been no change in ownership or 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 it has no interest whatsoever, directly or indirectly in any other liquor establishments in <br />Minnesota. If so. gr-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 tor 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 cnminal <br />liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below <br />5 Licensee confirms that dunng the past license year, a summons has not been issued under the Liquor Liability Law <br />(Dram Shop) .MS 340.A.S02 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 penod. <br />Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. SIOO.OOO in cash or securities or SlOO, 000 surety bond may be submitted In lieu of liquor <br />liability. <br />Licensee Sicnature Date <br />(S.inature certifies all above information to be correct and license has been approved by city/county. <br />Citv Clerk'Countv .Auditor Signature Date <br />i Signarare certifies that renewal of a liquor, wine or club license has been approved by the city/ccunty as stated above <br />Countv Attomev Signature Date <br />Countv Board issued licenses onlv (Sianarure certifies licensee is eligible for license).• • • <br />Police.Shenff Sisnature Date <br />iSignarare certifies licensee or associates have not been cued during the past five years for any statefiocal liquor law <br />violations tcnminal/civil). Report violations on back, then sign here.