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<br />1 <br />I. <br /> <br /> <br />Minnesota Department of Public Safety <br /> <br />Alcohol and GambUng Enforcement <br />444 Cedar Street, Suite 133 <br />St. Paul. MN 55101-5133 <br />651-296-6979 · TIY 651-282-6555 · Fax 651-297-5259 <br /> <br />'-, <br /> <br /> <br /> <br />l,itBIsee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />ClerldCounty Auditor should submit this signed renewal with completed license and licensee liquor liability for the new <br />license period. City OerklCounty Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />caneellation. <br /> <br />License Cod~ GIYI'j::\~ License Period Ending 1 ;::&/::?1/?L7JfJI@# 1=.111 <br />City/County where license approved. Cent erv ill e <br /> <br />Licensee Name <br /> <br />Kel1v's Korner Inc. <br /> <br />1Iade Name <br /> <br />Kellv' 5 Kor"ner" <br /> <br />Licensed Location address " 709B Cent e'rv i 11 e Rd <br /> <br />City, State, Zip Code <br /> <br />Hutl.9.. MN 5503B <br /> <br />" <br /> <br />Business Phone <br /> <br />651/653-1469 <br /> <br />LICENSE ~: Off Sale $ 100.. 00 On Sale $ 2500. 00 Sunday $ 200: 00 <br /> <br />By signing thiS renewal appUeation, appHeant certifies that there has been no cIumge In ownership on the above <br />named Dcensee.; For changes In ownership, the Dcensee ~ed above, or for new Hceusees, foB appDeations should <br />be used. See back of this appDeation for further Information needed to complete this renewal <br /> <br />AppHcant's lligPatnre 'on this renewal confirms the fnnnwing: FaDnre to nwort any of the following wDl result in fines. <br /> <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 cityltownship/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 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 />S. 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 /> <br />Licensee has attached a Dquor IiabDity insnrance certificate that corresponds with the license period In city/county <br />where 6cense Is issued. $100,000 In cash or seeurltfes or $100,000 surety bond may be submitted In Dea of Hquor <br />UabDity. <br /> <br /> <br /> <br />Licensee Si Date <br />(Si~ certifies all above information correct ~ license has been approved by city/county.) <br /> <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 /> <br />County Attorney Signature Date <br />County Board issued licenses only (Signature certifies licensee is eligible for license). <br /> <br />Police/Sheriff Signature Date <br />(Signatufe certifies licensee or associates have not been cited d <br />(r.riminallcivil). Report violations on back, then sign here. <br /> <br /> <br />9093-98 <br />