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Minnesota Department of Public Safety , <br /> Alcohol and Gambling Enforcement <br /> .� 444 cedar street, suite 133 <br /> St.Paul,MN 55I01-5133 <br /> 651-296-6979 . TW 651-282-6555 . Fax 651-297-5259 <br /> RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br /> No llecnse will e approved or released until the$20 Retailer ID Card fee is received by MN Liquor Control <br /> L*censee:l 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 /> License Code! _ MCLONS j 2 License Period Ending 1 3 12137 2002 �D# <br /> City/County where license approved.Ro s e v i 11 e <br /> Licensee Name Midland Hills Country Club Inc. <br /> Trade Name Midland Hills Country Club <br /> Licensed Location address 2001 Fulham St <br /> City, State, Zip Code Roseville, M N 5 5 1 1 3 <br /> Business Phone 651/631-0440 <br /> LICENSE FEES: Off Sale $O. 00 On Sale$ 650 . 00 Sunday$ 200.00 <br /> By signing thii 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 /> Ayolicant's signature on this renewal confirms the following: Failure to report any of the following will result in fines. <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 confirms that it has never had a liquor license rejected by any city/township/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 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 /> 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 <br /> liabilitv. <br /> V <br /> Licensee Signature Date �� Cv_ Z- <br /> (Signature certifies alfabove information to be corl`ec n has been approved by city/county ) <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 /> County Attorney Signature Date <br /> County Board issued licenses only (Signature certifies licensee is eligible for license) <br /> Police/Sheriff Signature -- Date k1— t -c-)-– O Z <br /> (Signature certifies licensee or associates have not been cited during the past five years for any state/local liquor law violations <br /> (crim.inaUcivil),Report violations on back, then sign here <br /> PS 9f19YA-9P <br />