2002-12-09 CC Packet - Laserfiche WebLink

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Minnesota Department of Public Safety Alcohol and Gambling Enforcement 444 Cedar Street, Suite 133 St. Paul, MN 55101-5133 651-296-6979' TrY 651-282-6555 . Fax 651-297-5259 RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE '~o'Ii#~~':;,~l'~~,',:ip?i?S~'Bi'r~I~a$~d:'~*:tlr~,~$20t~~#U"1~'~:,':IL\;:~~rd:-'fe,~)s,'~;;~i~~::bY'~~,r4~~9~:~'~ntr9~;~ Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period. City Clerk/County Auditor are also required by M,S. 340A.404 S. 3 to report any license cancellation. License Code .'-'~"lBa License Period Ending 1 ~ J,~ 1. J~()(j? ID# City/County where license approved.c e n t e r V i 11 e F,111 Licensee N arne Kelly's Korner Inc. Trade Name Ke11yls Korner Licensed Location address 70S8 C 'f.: n t; e f' Y i 11 e Rd City, State, Zip Code Huge, MN 55038 Business Phone 651/653-1469 LICENSE FEES: Off Sale $100. 00 On Sale $ 2500.00 Sunday $ 200.00 By signing this renewal application, applicant certifies that there has been no change in ownership on the above named licensee. For changes in ownership, the licensee named above, or for new licensees, full applications should be used. See back of this application for further information needed to complete this renewal. Aoolicant's signature on this nmewal confirms the following: Failure to cenort any of the foilowinl! will result in fines. 1. Licensee confirms it has no interest whatsoever, directly or indirectly in any other liquor establishments in Minnesota. If so, give details on back of this application, 2. Licensee confimls that it has never had a liquor license rejected by any cityltownship!county in the state of Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. 3. Licensee confIrms that for the past five years it has not had a liquor license revoked for any liquor law violation (state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. 4. Licensee confInns that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations. If violations have occurred, please give details on back of thi~ renewal, (hen sign below. 5. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below. 6. Licensee confirms that Workers Compensation insurance is in effect for the full license period. Licensee has attached a liquor liability il15urance certificate that corresponds with the license period in city/county where license is issued. $100,000 in cash or se-curities or $100,000 surety bond may be submitted in lieu of liquor liability. Date /0 ;p () (:. o be correct and license has been approved by cltY'IC.OUHty.) Licensee Signature (Signature certifIes all above informatio City Clerk/County Auditor Signature Date (Signature certifies that renewal of a liquor. wine or club license has been approved by the city/county as stated above.) Date County Attorney Signature County Board issued licen~y ~.i~rtifies licens is ligible for license). Police/Sheriff Signature Rl.- "./' (Signature certifies licensee or associates have no ited during the pa (criminal/civil). Report violations on back, then sign ere. Date /v five years for any statellocal iquor law violations PS 9093-98