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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 />RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES <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 CMBS <br />City/County where license approved, <br /> <br />License Period Ending <br />Centet~vi lIe <br /> <br />12/.31/200!.ID# <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 />7098 Centerville Rd <br /> <br />City, State, Zip Code <br /> <br />Business Phone <br /> <br />Hugo, t"iN 550.38 <br /> <br />651/65.3-1469 <br />LICENSE FEES: Off Sale $ On Sale $ Sunday $ <br />1 171171 IZi I2l ,=. t:" l71l7! IZi 171 '='171 1'71 1'7117J <br />By signing this renewal applicatroll;applicant certifies that there hasb~mrt~hange in ownership on the atJCJ\rll'bll'lired <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 sil!nature on this renewal confirms the followinl!: Failure to report any of the followinl! will result in fines. <br /> <br />I, 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. 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 "eropt if sse han $25,000 at on sale, or $50,000 at off sale). <br /> <br /> <br /> <br />D e <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 c~rtifies licensee is eligible for license). <br /> <br /> <br />Date <br />e patf:ve years for any state!local liquor law violations <br /> <br />~f? PS 9093-98 <br /> <br />C? I/;~ <br /> <br /> <br />