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Renewal Application for Optional Liquor 2AM License Type: 2AM- 100K -500K Expires On: November 1, 2013 ID Number: 33600 DBA S & B Center Corp. Kelly's Korner 7098 Centerville Rd Centerville MN 55038 Business Phone: 6516537791 If any of the above licensee information is not correct, please make corrections as necessary. Licensee must report previous 12 month on sale alcoholic beverage gross receipts by checking one of the boxes below. Next to the box you check is your 2 AM license fee. Make check payable to: Alcohol and Gambling Enforcement Division (AGED). Mail this application and check to: AGED, 444 Cedar St, Suite 133, St Paul, MN 55101 -5133. $300 2 AM license fee - Up to $100,000 in on sale gross receipts for alcoholic beverages $750 2 AM license fee - Over $100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages _$1000 2 AM license fee - Over $500,000 in on sale gross receipts for alcoholic beverages _$200 2 AM license fee - 3.2% On Sale Malt Liquor licensees or Set Up license holders _$200 2 AM license fee - Did not sell alcoholic beverages for a full 12 months prior to this application �[ Yes _No Does the city or county that issues your liquor license allow the sale of alcoholic beverages until 2 AM? City Clerk(County Auditor Signature Date (I certify that the city or county of _ approves the sale of alc� beverages until 2AM) Licensee Signature Date (I certify that I have answered the above question ui and correctly) Licensee Minnesota Tax ID Number (Required): / 7 a� • 3 3 p 0 Licensee: Prior to submitting this application to the Alcohol & Gambling Enfocement Division you must have this form signed by your local city or county licensing official Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 444 Cedar Street, Suite 133, St. Paul, MN 551014133 Telephone 661- 201 -TSOO Fax 661- 297-626® TTY 661- 282 -6555 wwwdps.state.mmus 2amRenewa12004 17