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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar St. Suite 133, St Paul. MN 55101-5133 <br />(651)296-9519 <br />FAX (651)297-5259 TTY (651)282-6555 <br />APPLICATION FOR CLUB ON SALE RETAIL LIQUOR LICENSE <br />This application (PS 9016-98) shall be completed by an officer of the club seeking a license. This application and the proof of <br />'•quor liability Insurance must be filed with the city clerk or the county auditor. To qualify for a license a club must have at least <br />fifty members, been in continuous existence .for at least three years, have an elected governing board and limit sales to <br />members and bona fide guests only. The annual license fee is set by statute (M.S. 340A.408). Granting of a license by the city <br />cr county is discretionary. P i /■ <br />Workers Compensation Insurance Company^* wh( Lo>*-p^< <br />Licensee ’s Sales and Use Tax ID Number <br />Policy if <br />To apply for a sales and use tax number call (651)296-61d1or 1’■BOO-657-3777 <br />Ccrporation Name <br />ih/i <br />Lcense Lcc3tion(Sueet Address) <br />Municipality <br />BuitCing C-vvner's Name <br />k.'e there a-^ delinquentA:e then <br />axes or th; property?Yes (3' <br />iN'ame of Member of Managing Board DOB <br />v/r/w <br />Social Security t <br />Club Trade Name or DBA <br />License Period <br />FROM/-o?/• £> O J0/J “2/'00 <br />County <br />IL <br />State <br />Business Phene <br />Zip Code <br />^S-29/ <br />Building Owner's Address <br />Club Manager's Name <br />•///» f Oi/ <br />Address .j <br />j \'ame of P/ember of Managing Board <br />• Name of Member of Managing Board <br />same of Member of Managing Board <br />DOB <br />j/yvi <br />DOB <br />Social Securiry U Address ^ <br />Social Security u Address / S'^ <br />4'fZA iCs.^ A t/^ I <br />003 Social Security 0 Address <br />The Licensee must have one of the following; <br />CHECK ONE <br />B. <br />c« <br />C. <br />Liquor Liability Insurance(Dram Shop) - $50,000 per person: $100,000 more than one person; $10,000 property <br />destruction: $50,000 and $100,000 for loss of means of support ATTACH "CERTIFICATE OF INSURANCE" TO <br />THIS FORM <br />A Surety bo' d from a surety company with minimum coverage as specified above in A. <br />A certificate from the State Treasurer that the Licensee has deposited with the State. T.njst Funds having a market <br />Wul^_ -.1 . W W 1 W 1 W W W W w 1 1 1 <br />C" «9 Datt cf Club Char.er <br />fVettra.-s cr Fraternal <br />^ ^rganizaten <br />Date of Incorporation <br />/- .2/' ^ 7 <br />Number of Years of <br />Continuous Existence <br />of the Club ^ <br />Number of Years in ^ <br />j Current Quartere ^ <br />Number of Club <br />Members / <br />Will the Club be Issued a Lawful Gambling <br />License? YES