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2002-12-09 CC Packet
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2002-12-09 CC Packet
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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' TrY 651-282-6555 . Fax 651-297-5259 <br /> <br /> <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />'~o'Ii#~~':;,~l'~~,',:ip?i?S~'Bi'r~I~a$~d:'~*:tlr~,~$20t~~#U"1~'~:,':IL\;:~~rd:-'fe,~)s,'~;;~i~~::bY'~~,r4~~9~:~'~ntr9~;~ <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 .'-'~"lBa License Period Ending 1 ~ J,~ 1. J~()(j? ID# <br />City/County where license approved.c e n t e r V i 11 e <br /> <br />F,111 <br /> <br />Licensee N arne <br /> <br />Kelly's Korner Inc. <br /> <br />Trade Name <br /> <br />Ke11yls Korner <br /> <br />Licensed Location address 70S8 C 'f.: n t; e f' Y i 11 e Rd <br /> <br />City, State, Zip Code <br /> <br />Huge, MN <br /> <br />55038 <br /> <br />Business Phone <br /> <br />651/653-1469 <br /> <br />LICENSE FEES: Off Sale $100. 00 <br /> <br />On Sale $ <br /> <br />2500.00 <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 <br />named licensee. For changes in ownership, the licensee named above, or for new licensees, full applications should <br />be used. See back of this application for further information needed to complete this renewal. <br /> <br />Aoolicant's signature on this nmewal confirms the following: Failure to cenort any of the foilowinl! 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 confimls that it has never had a liquor license rejected by any cityltownship!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 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 thi~ renewal, (hen 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 il15urance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or se-curities or $100,000 surety bond may be submitted in lieu of liquor <br />liability. <br /> <br /> <br />Date /0 ;p () (:. <br />o be correct and license has been approved by cltY'IC.OUHty.) <br /> <br />Licensee Signature <br />(Signature certifIes all above informatio <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 as stated above.) <br /> <br />Date <br /> <br />County Attorney Signature <br />County Board issued licen~y ~.i~rtifies licens is ligible for license). <br /> <br />Police/Sheriff Signature Rl.- "./' <br />(Signature certifies licensee or associates have no ited during the pa <br />(criminal/civil). Report violations on back, then sign ere. <br /> <br /> <br />Date /v <br />five years for any statellocal iquor law violations <br /> <br /> <br />PS 9093-98 <br />
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