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Item#17-CC Agenda-01/14/OR <br /> Lru'nAco,Y h,,,�l,.,[Page 17 r.,/30] <br /> Minnesota Department of Public Safety <br /> c <br /> ykia ° Alcohol and Gambling Enforcement <br /> oo. < 444 Cedar Street,Suite 133 s;t, <br /> ml: • <br /> St.Paul,MN 55101-5133 <br /> 651-201-7507•TTY 651-282-6555•Fax 651-297-5259 <br /> RENEWAL OF LIQUOR,WINE, CLUB OR 3.2% LICENSES <br /> Nn hcehae sPdl be approved or teles eauntil the$20 Retailers Card€ee• irece,ved by MN Lagfigr Control, (3 g%Licena ex not �4 t; <br /> Licensee:Please verify your license information contained below.Make corrections if necessary and sign.City <br /> Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license <br /> period.City Clerk/County Auditor are also required by M.S.340A.404 S.3 to report any license <br /> cancellation. <br /> License Code MCLONSS License Period Ending 12/31/200g# 2821 <br /> City/County where license approved. Orono <br /> Licensee Name Spring HiI1 Golf Club Inc, <br /> Trade Name <br /> Spring Hill Golf Club <br /> Licensed Location address <br /> 725 6th Pave N <br /> City,State,Zip Code <br /> Orono, MN 55391. <br /> Business Phone <br /> 952/473—1517-iki <br /> LICENSE FEES:Off Sale$ On Sale$ Sunday$ <br /> By signing this renewal applicator, plicant certifies that there has bee 0c1:16W e in ownership on the abg. ninsln11%' <br /> licensee.For changes in ownership,the licensee named above,or for new licensees,full applications should be used.See <br /> 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 any 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 has never had a liquor license rejected by any city/township/county in the sate 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 convicted of any criminal <br /> violations or imposed with any civil penalties.If so,please report on back of this application. <br /> 5. Licensee confirms 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 license period. <br /> Licensee has attached a Iiquor 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 liabil- <br /> ity.(3.2%liquor licenses •re exempt if sales are less than$25,000 at on sale,or$50,000 at off sale). <br /> /2/ . <br /> / 7 <br /> / /U <br /> • — to <br /> (Signature certifies all ahoy" information to be correct and license has been approved by city/county.) <br /> City Clerk/County Auditor Signature _ Date <br /> (Signature certifies that renewal of a liquor,wine or club license has been approved by the city/county as stated above.) <br /> _County Attorney Signature Date <br /> County Board issued licenses (Signat ertifies eusee is eligible for license). <br /> Police/Sheriff Signature_ • • Date 7•017g" <br /> (Signature certifies licensee or ass sates have not been cited during the past five years for any state/local liquor law violations <br /> (crirninal/civil).Report violations on back,then sign here. <br /> PS 9093-05 <br />