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V -A <br />■I- <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar St.. Suite 133 <br />St.Paul.M.N 55101-5133 <br />612-296-6430 • TTY 612-282-6555 • F.\X 612-297-5259 *'**' <br />______RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE______ <br />No license will be approved or released until the S20 Retailer ID Card tec is received by MN Liquor Control <br />Licensee; Plea.se 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/County Auditor are also required by M.S. 340.A.404 S. 3 to report any license <br />cancellation. <br />License Code MCLQf>I5 License Period Ending .1 S/Z1/ 13 ID #----Li <br />City/County where license approved 0 r o n o <br />Licensee Name Wayzata Country CI u Sd Inc <br />Trade Name U'ayzata Country Club <br />Licensed Location address SCO V*ayzata Blvd/Sox <br />City, State, Zip Code Cr o n o » MN SS391 <br />Business Phone t ol 2) A73-S2AS <br />LICENSE FEES; Off Sale $ OnSaleS 100. CO Sundays 200.00 <br />Bv 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 />ADPlicant's signature on this renewal confirms the following: Failure to report anv of the.foUow.i.ng wjll re5WU in filKSi <br />1. Licensee confimis it has no interest what.soever. 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 /township/county in the state of <br />Minnesota. If ever rejected, please give details on the back of this rcnevsal. 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 Law <br />t Dram Shop) MS 340.A.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 liabilitv insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in ca.^ or securities or $100,000 surety bond may be submitted In lieu of Uquor <br />liability. ^ . <br />Date / /________Licensee Signature <br />(Signature certifies all abo^* infeimati^ to-^^nrect and license has been approved by city/county. <br />DateCity Clerk/County Auditor Signature______________________________________ <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above. <br />Countv .Atto -tcy Signature Date <br />County Boarc issued licenses only (Signature certifies licensee is eligible tor licensei. <br />Police/Sheriff Signature______________________________________________ <br />(Signature certifies licensee or associates have not been cited during the past live years tor any state/local liquor law <br />Violations (criminal/civ il). Report violations on back, then sign here. <br />Date <br />PS 9093-9S