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<br /> <br />Minnesota Department of Public Safety <br /> <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite 133 <br />St. Paul, MN 55101-5133 <br />651-201-7507 · TTY 651-282-6555 · Fax 651-297-5259 <br /> <br />RENEW AL OF LIQUOR, WINE, CLUB OR 3.2 % LICENSES <br /> <br /> <br /> <br /> <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 /> <br />License Code OFSL <br />City/Colmty where license approved. <br /> <br />License Period Ending <br />Centei'ville <br /> <br />12/ 31 /~::00ib# <br /> <br />1508'3 <br /> <br />Licensee Name <br />Trade Name <br /> <br />GNA,-^J Inc. <br /> <br />Centerville Liquor Barrel <br />Licensed Location address <br /> <br />*7093 20th Ave S <br /> <br />City, State, Zip Code <br /> <br />Centerville, MN 55038 <br /> <br />Business Phone <br /> <br />6~.s 1,1 tj.2f,--66 ,T 4 <br /> <br />LICENSE FEES: Off Sale $ On Sale $ Slmday $ <br /> <br />B ' . h' I I' ~.00. 0G~ 'ft h h h 0.00- . h' h 0. 00 d <br />Y slgmng t IS renewa app Ica'fion, appTIcant certl es t at t ere as been no change ID owners Ip on t e abOve name <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 /> <br />Applicant's si~nature on this renewal confirms the following-: Failure to report any of the following- will 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 city/township/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 crinIinal <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 tlJe past license year, a summons has not been issued under thc 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 liquor 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 are exem t i ales are less than 25 0 at on sale, or $50,000 at oft' sale), <br /> <br /> <br /> <br />ormation to be correct and license has been approved by city/county.) <br />City ClerkJr.ounty Auditor Signature Date <br />(Signature certifies that renewal of a liquor, wirIe or club license has been approved by the city/county as stated above.) <br /> <br />County Attorney Signature <br />County Board issued licenses 0 <br /> <br />(Signature certifies licensee or associates have not een cited during tlJe past five years for any state!loealli uor la <br />(criminal/civil). Report violations on back, then sign here. <br /> <br /> <br />Date <br /> <br />PS 9093-05 <br /> <br />/;;1~ <br />