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Minnesota Department of Public Safety ytMdr , <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite 222 �f <br />' St. Paul, MN 55101 <br />651-201-7507 • TTY 651-282-6555 - Fax 651-297-5259 <br />RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES <br />No license will be approved of released until the y_U Reviler ID Cvd fee n teceiv ed by &IN Liquor Control • (3 2% Licenses exempt) <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Clerk/County Auditor should subunit 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 />License Code Lic nse Period Ending 1 `-1 " 1 ` `"�Cill0i# ` �F`"Vj <br />City/County where license approved. ' e m L-a h e — - <br />Licensee Name L 0{, n f r—v Lounge I n e, <br />Trade Name Cou-ntry L-. o u n g o <br />Licensed Location address <br />1590 N Hoffman Rd (West) <br />City, State, Zip Code <br />Lem Lake,, 11N 5110 <br />Business Phone <br />651. / 484-47 .fit,) <br />Ll N 115 • FEES: Off Sale $ On Sale $ Sunday $ <br />By signing this renewal application, applicant certifies that there has been no change in ownership on the above named <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 />Applicant's signature on this renewal confirms the followine: Gailure to re�nrt�mv of the following will result in fines <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/towliship/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 bas 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 will be kept in effect during the license period. <br />Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor liabil- <br />ity. (3.2% liquor licenses are excjnpt if sales are less than $25,000 at on sale, or $50,000 at off sale). <br />(Signature certifies'ull above information to be correct and license has been approved by city/county.) <br />("ry ('Ierk/('onnty AudiwLSibilaLure T)atr <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above.) <br />ChunV-Hilo ney�Signature flat <br />County Board issued licenses only (Signature certifies licensee is eligible for license). <br />(Signature certifies licensee or associates have not been cited during the past five years for any state/local liquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br />PS 9093-10 <br />