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Minnesota Department of Public Safety Alcohol and Gambling Enforcement 444 Cedar Street Suite 133 St Paul, MN 55101-5133 65 I-296-6979 . TTY 65 i-282-6555 . Fax 65 I-297-5259 RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE No lice=will be approved of released until tk$20 Retailer ID Card fee is received by MN Liquor Control Licensee• Please verify your license information contained below Make corrections if necessaq and sign City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period. City Clerk/County Auditor are also required by MS. 340A.404 S. 3 to report any license cancellation. License Code _ONS w License Period Endin� _ 12 L 3 11-2002 i to 3406 nrn•Ain , �•M'"Nw- City/County where license approved.R o 5 e v ill e Licensee Name Pavlick Holding Co. Trade Name 01 Mexico Licensed Location address 1754 N Lexington Ave City, State Zip Code R o s e v i l l e , MN 5 5 1 1 3 Business Phone 651/487-2847 LICENSE FEES: Off Sale S O• 00 On Sale S 7000.00 Sunday$ 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. Applicant's sit-mature on this renewal confirms the followine: Failure to report any of the followine 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 confirms that it has never had a liquor license rejected by any city/township/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 confirms 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 this renewal then 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 insurance certificate that corresponds with the license period in city/county where license is issued. $100,000 in cash or securities or$100,000 surety bond may be submitted in lieu of nquor liability. Licensee Signature Date (Signature certifies all above information to be correct and license has been approved by city/county ) 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 ) County Attorney Signature Date County Board issued licenses only (Signature certifies licensee is eligible for license) Police/Sheriff Signature � �,, . Date ] _ I Z it (Signature certifies licensee or as vcaes h ve not been cited during the past five years for any state/local liquor law violations (criminal/civil) Report violations on back, then sign here PS 9093-98