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°"' Minnesota Department of Public Safety Alcohol and Gambling Enforcement x 444 Cedar Street. Suite 133 St Paul MN 55101-5133 TTY 65 I-282-6555 . Fax 65 I-297-5259 RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE No license will be 4pproved or released until tic$20 Retailer ID Card fee is received by NiN Liquor Control Licensee: Please verify your license 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 cancellation. License Coldei rWRJ n s e P e r i o d E n d i n g 1 2 l �_ 021 D#_---.-70M City/County where license approved.R o s e v i 1. 1 e Licensee Name Stephens Liquor Store Inc. Trade Name Fairview Wines & Spirits Licensed Location address 2579 N Fairview R v e City, State,Zip Code R o s e v i 1 1 e, MN 5 5 1 1 3 Business Phone 6511636-7229 LICENSE FEES: (off Sale s 200 a 00 On Sale 0 . 0 0 Sunday 0 . 0 0 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 sienature on this renewal confirms the ollowinty•Failure to report any of the foll,owino 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 file 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 liquor 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 UHL-111� U:64t:� Date l. 7 (Signature certifies licensee or sociate have not been cited during the past five years for any state/local liquor law violations (criminaVcivil).Report violationN on back,then sign here. PS 9093-98