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<br />~i~D <br />i\;)(j <br /> <br />5 2000 <br /> <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 />651-296-6979. TTY 651-282-6555. Fax 651-297-5259 <br /> <br /> <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br /> <br />No license will be approved or released until tbe $20 Retailer ill Card fee is received by MN Liquor Control <br /> <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new <br />license period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />cancellation. <br /> <br />License Code CMBS <br />City/County where license approved <br /> <br />License Period Ending 12/31/2000 ID# <br />Centerville <br /> <br />6111 <br /> <br />Licensee Name <br /> <br />Kelly's Korner Inc. <br /> <br />Trade Name <br /> <br />Kelly's Korner <br /> <br />Licensed Location address <br /> <br />7098 Centerville Rd <br /> <br />City, State, Zip Code <br /> <br />Hugo, MN 55038 <br /> <br />Business Phone (651) 553-1469 <br /> <br />LICENSE FEES: Off Sale$ <br /> <br />100.00 <br /> <br />OnSale$ 2,500.00 <br /> <br />Sunday $ <br /> <br />200.00 <br /> <br />By signing this renewal application, applicant certifies that there has been no change in ownership on 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 /> <br />Applicant's signature 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 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 <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. $1 0,000 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor <br />liability. <br /> <br />Licensee Signature <br />(Signature certifies all above information t <br /> <br /> <br />Date <br />e correct and license has been approved by city/county.) <br /> <br /> <br />City Clerk/County Auditor Signature Date <br /> <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 /> <br />County Board issued licenses onl~ure certifies licensee is eli ),ne Ylicense). <br /> <br />Police/Sheriff Signature c:zv""Z /y. ??/~- ::> Date <br /> <br />(Signature certifies licensee or associates have not been cite u' g tl>e past five years for any state/local liquor law violations <br />(criminal/civil). Report violations on back, then sign here. ~.e .b~u:4.. <br />PS 9093-98 <br /> <br />