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Minnesota Department of Public Safety Alcohol and Gariibling Enforcement 444 Cedar Street, Suite i 33 St..Paul. MN 55.101.5133 01.201-7507 •Try 651.282=6 55 • Fax 65.1.297-5259 RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES Na license will be approvedor released until the S20 Retailer ID Card fee is receiyed.by MN Liquor Control • (3.2 1c Licenses. exempt) Licensee: Please verify your Iicense 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 cancefla tlon. :License Code DHSS License Period Ending 7. Y 1 r`a'17.,1 8# aziae, City/Crnuity where license approved. -iain L= i.: Licensee Name Trade Name. Co Lint r,y Lot! �ga Tiic:. Cat_tritr'yr LD•r.rnj Licensed Location address City, State, Zip Code. Business .Phone N lH 7 f f to :i : R _I e tii Li-,rrl r:l 5.54 1. �, t t�5:1r 84-477t LICENSE Ff`.ES: Off Sale.$ On Sale S Sunday $ By signing.tfiis renewal applicaiinnk,734plitant certifies tbat.there has beeiNEdaxait in ownership on the alit: .14a s'I licensee. Far changes in own.ersbip, the licensee: named above, or for new licensees, full' applications should beused. See back. of this.applicatioo for further information needed to.compleie this renewal. A.pp]icanr,s sign tare tin this re elf waf c firm the following: Failure to• report any of the foilowjng.wif 05n1t in.fines, 1.:. Licensee confirms it.has no interest whatsoever; directly or. indirectly:in arty other liquor establishments in Minnesota. If so give details on back of. this ap.plication.. 2. Licensee confirms that it has never had a liquor Iicense rejec.tcd by any cityltowrishiplcourity in the sate of Minncsota..Lf ever rejected, please :give. details on. the hack of this. renewal, then sign below. .3. Licensee .confirins.. that for the past five years it has not had a ii.quo.r. 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.. confirms. that during the past five years it or its employees have not•becn convicted of any criminal •violations or imposed with .any .civil penalties. if so, please•report on back of this:application. 5. Licensee confirms that dur•ing•the past license year„a sumrrions has not been issued under the Liquor Liability Law (Dram Shop) MS 340A..802. if yes, attach. a..eupy Of the summons, tben.sign below, Licensee confirms that Workers Compensation insurance. is in effect for the full license period. • Licensee bas:attached a liquor liability insurance certificate that corresponds with the license. period in city/county where license.is issued. $1.00,000 in cash or securities or $1i00,000.surety bond.may be submitted in Ben of fig uorliabil- ity,e (3.2%e liiquor.licenses are emptif sales are less than $25,000.at on sale, or $50,00o.at off sale).. os .(Signature certifies A11above information to be correct. and Iicense has been.approved by. city/county.) City.Cierk(County Auditor Signature 0,,ie (Signature certifies that renewa.] of a liquor,. wine•or.club license has been approved by the city./county as s.tated:above,) nyiny_Attorney Signature Datc Ciiunty Board issued ricenses.only (Signature certifies licensee is eligible. for.license}_ PolicedSSerif(: Signature_ Date (Signature certifies licensee or associates have•n.ot been. cited dw•ing the past five years for any state/local liquor law violations (criminallcivil). Report violatinos..on back. then sign hero. PS 9093-05