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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 />651-296-6979. TTY 651-282-6555. Fax 651-297-5259 <br /> <br /> <br />RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES <br /> <br /> <br />Licensee: Please verify your license infonnation 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 CMBS <br />City/County where license approved. <br /> <br />License Period Ending <br />Cent et~v i 11 e <br /> <br />12/31/2121I21ID# <br /> <br />6111 <br /> <br />Licensee Name <br />Trade Name <br /> <br />Kelly's Korner Inc. <br /> <br />Ke 11 y' s Kot~net~ <br />Licensed Location address <br /> <br />712198 Centerville Rd <br /> <br />City, State, Zip Code <br /> <br />Business Phone <br /> <br />Hugo, MN 5512138 <br /> <br />651/653-1469 <br />~-~~~-LICENSE FEEs-:-OffSaJe$ hhUfiSaIe $~m __m____ ---~-~--Siliii:Iay $---~----~--~----- -. -~- <br /> <br />By signing this renewal appliJ&'&';a~8hcant certifies that there has,~W<-1l~e in ownership on the a6llt~b~ <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 sienature on this renewal confirms the foUowin!!: Failure to report aDY of the foUowin!! will result in fines. <br /> <br />1. Licensee confinns it has no interest whatsoever, direcdy or indirecdy in any other liquor establishments in <br />Minnesota. If so, give details on back of this application. <br />2. Licensee confinns 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 confinns 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 confinns 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 confinns that during the past license year, a SUmmons has not been issued under the Liquor Liability <br />Law (Dram Shop) MS 340A.802.lfyes, attach a copy of the summons, then sign below. <br />6. Licensee confinns 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. 100,0 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor liabil- <br />ity. (3.2% liquor lice are xempt ifs e han $25,000 at on sale, or $50,000 at oft'sale). <br /> <br /> <br /> <br />o be correct and 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 a~ stated above.) <br /> <br />County Attorney Signature Date <br />County Board issued licenses only (Signature ~ertifie~ licensee is eligible for licen,~e). <br /> <br />Police/Sheriff Signature Date <br /> <br />(Signature certifies licensee or associates have not been cited during the past five years for any state/localliquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br /> <br />PS 9093-98 <br /> <br />J7!) <br />