|
<br />1---
<br />
<br />d;,NQFi'U~
<br />
<br />(~
<br />~
<br />
<br />Minnesota Department of Public Safety
<br />
<br />Akohoi and Gambling Enforc~m.ent
<br />444 Cedar Street, Suite 133
<br />St. Paul, lVlN 5510 1-5133
<br />651-296-6979' TTY 651-282-65550 Fax 651-297-5259
<br />
<br />
<br />RENEWAL iOF UQiU(}lR, WllNE, OR cum LICENSE
<br />
<br />N(j,licen'se"wiH'be:~p_Pfd~,ed,pf'releas~#::tlll~l!,tb.e-$.~~:~R~t<l#Ic~iI)::--_~#?~-,~~e;'~,;~ceiv,~~::;~f::~_":~~~~,9_i.~~ri#~j:
<br />
<br />Lk:cnsee:_ Please verify your license information contained below. Make corrections if necessary and sign. City
<br />CleridCounty Auditor should submit this signed renewal willi completed license and licensee liquor liability for the new
<br />license period. Cay CRerkfCOImty AuditDr are :Jjso required by M.S. 340A.404 S. 3 to report any license
<br />c3nc.eUadon.
<br />
<br />License Code i-:;ViBS
<br />City/County where license approved
<br />
<br />License Period Endina 12.1 31.1 200 1 ID#
<br />C2nt2t'vill~ ~
<br />
<br />6 i l.1
<br />
<br />Licensee Name
<br />
<br />Kellj~5 Kwrner Inco
<br />
<br />Trade Name
<br />
<br />H.=llyfs l-{crner'
<br />
<br />Licensed Location address
<br />
<br />7098 Centerville Rd
<br />
<br />City, State, Zip Code
<br />
<br />HLigO,. [lilN 550~3B
<br />
<br />Business Phone { E/5 t
<br />
<br />553"-1,ct'(;'3
<br />
<br />LICENSE FEJES: Off Sale$
<br />
<br />100,. 00
<br />
<br />'"' ":; 50' n 00
<br />On ~ale $ c.." - ~ -
<br />
<br />Sunday $
<br />
<br />200.0()
<br />
<br />~y :::;igillmg this ;r~new,tId' .apgJlk,l]Jtion~ :1IppHC':u~t <C~J',jjJiJ~s il:h~i tlleY'e has b~~n. no dJ.ange in ownership on the .above
<br />named ~ken6'ft. !Fm"cha.nges in owneJrsh.jp, the ~itCf5]se<e named ahove? <Or' [or new Hceli.lls<ees, fun appfticanoIW sbould
<br />be used." See lJ...u~t( {)f :this 1n/[llpj]c~tiOli] for ft"urlheli" information ne~dcd to 1.:ompicte this renewal.
<br />
<br />}ll,iDp-Jkant1:3 ,Jh!na~i'JI.rt on ~!lJns rencwai i:nn.Urms th.e foHnwin.2:IF:illnU:rr~ ;to rellNwt any of the IoiJowing win it"~suH in fines.
<br />
<br />I.
<br />
<br />Licl:::nsee confirms it has no interest whatsoever, directly or indirectly in any other liquor establi'shments in
<br />rlIinnesota. If so, give details on bude of this application.
<br />Licensee confirms that it has never had a liquor license re:jected by any city/township/county in the state of
<br />ivlinnesota. If ever rejected, pletlSe give details on. the back of this renewal, then sign below.
<br />Licensee confirms that for the past five years Lt bas not had a liqnor license revoked for ilny liquor law violation
<br />(;;tate or local). If a l'CVQctltion has occurred, please give details on thc back of this renewal, then sign below.
<br />Llcens~:;: ,:oniirms [hal dUlil1g tl1..:: p~,st five ye:~s it or its employees have not been cited for ~my civil or criminal
<br />liquor law vioLations. if vlolmions have occurreq, pleJ.~c give details un back of this renewaL then sign below.
<br />Licet1sc~ confirme, that during tile past license year, a snmmOl1S lw::; not been issued under the Liquor Liability
<br />Law (Dram Shop) l\,{S 340A.802. If yes, attach il copy of tbe summons, then sign below.
<br />Lic~nsee contIrms that Workers Compensation insurance is in effect for the full Ecense period..
<br />
<br />o
<br />
<br />3.
<br />
<br />4.
<br />
<br />J.
<br />
<br />6,
<br />
<br />Uc~nt;le.c elms ;j),U,"dl<ea 11 liq~Vlf .1n.:.luHity j1]sm'2!ncee~rillkate that CUIr:r~spOll1ld.s with Hac !ic~nse pcdod in dtj'!iCounty
<br />'~hce!",~ ~ic2nse is ~ssued. JJ1}O,~Mp~ jn I:.;:IlSU or se~m"iitie5 or $100,fiOO surety bond may be submitted in lieu of liquor
<br />bab,llty. /' /""/
<br />11/ J. / /.~-J
<br />?</> .,/ / \ / ./ ,>-<". I ,/ ./
<br />Lic~nsee Signature . ,.!-./l-~~?f~J-'.....( )/? /:t.t...::t--"., Date / tJ/ ? c... /i,.:p I
<br />(Signature celtifit:s all above irrformatioy.:[o be ~onecr and ]jcem;e has been approved by city/county.) ~
<br />
<br />City Clerk/County Auditor Sigmuure Date
<br />(Signature cenifieH ihar fenewJ.l or a liquor, wine or dub hcense .has been approved by the city/county as stated above,
<br />
<br />County Attorney Signature __-~:'_,_~
<br />...--' ......
<br />COllOly Board issued lice)l:>@:M7I1ij(Sir.:muure <...:ertifics lice.nseejs-<3l1g1ble to{nccu::;e). / . /'
<br />. , . ,. ~' /,/ ,.---"...,;' <'~ .,?;,,~ ,<,/ '\("', : ,---.,./ J/ ,/' ',// ,.... ? ~ ?~.- /~ ?
<br />POlICe/She-nit 0lgncuqre ",:7 ,t/,_~/ 1'..,../.-.:--,;;- "L-~- ~-~~.#z lj J _-/?;Z1;';::~~a[c /' ,2;/'/ ~ y' /
<br />(Slgnature c>:::rtifies Licen~~ee ur associates have nOL.!J;~~!Lc.ited during the past five f&.lrS for anysrttte/tocal !iqdor Im/ viul~ltions
<br />(crimin:.ll/civil). Rep\lrt yiOnrtiont:j'Tnri)"acR~ign here.
<br />
<br />Date
<br />
<br />PS 9093-98
<br />
|