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Renewal Application for Optional Liquor 2AM <br />License Type: 2AM-100K <br />Expires tin January 26; 2009.fD Numbers 13476. <br />DBA <br />Country Lounge Inc. <br />Country Lounge <br />3590 N Hoffman. Rd (West) <br />Gem Lake MN 55110 <br />Business Phone: 6514844770 <br />If any of the above licensee information is not Correct, please make corrections as necessary. <br />Licensee must report previous 12 month on sale alcoholicbeverage gross receipts by checking one of the boxes below <br />Next to the box you neck is your 2.AMlicense fee. Makecheck payable to; Alcohol and Gambling Enforcement <br />Division (AGED). Mail this application .and check to AGED, 444 Cedar St., Suite 133, St. Paul, MN 55101-5133. <br />$300 2 AMiicense.fee <br />$750 2 AM license fee <br />$1 000 2 AM license fee <br />�_-$200 2 AM license fee - <br />$200 .2 AM. license fee - <br />- Up to $140,000 in on sale gross receipts for alcoholic beverages <br />- Over $100,000, but not over $500,000 in on sale gross receipts for.alcoholic beverages <br />- Over $500,Q90 in on sale gross receipts for alcoholic beverages <br />3.2% On Sale Malt Liquor.licensees or Set tip. license holders <br />Did not sell alcoholic beverages fora full 12 months prior to this.applicativn <br />____ Yes _No Does the city or county that issues your liquor license allow the sale of alcoholic beverages until 2 AM? <br />City CI erk/Cou my Auditor Signature <br />(.l certify that the city or county of <br />2AM) <br />Liicensee Signature.. <br />{!certify that t have ans <br />(D4,11 <br />Date. a— +i —0 <br />approves the sale of alcoholic beverages :until <br />red the above questions truthfully and correctly) <br />Licensee Minnesota Tax ID Number (Required): <br />Date o ti;, \2_ 0 g <br />Licensee: Prior to submitting this application to the Alcohol & Gambling Enfocement <br />Division you must have this form signed by your local city or county licensing official <br />Minnesota Department of Public Safety <br />Alcoholand Gambling Enforcement Division (AGED) <br />444 Cedar Street, Suite 133, St Paul, MN 55101-5133 <br />Telephone 65.1-201-7500 Fax 651-297-5259 TTY 651-282-6555 <br />www d ps.state. rnn. us <br />'amRenewa12004. <br />