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Minnesota Department of Public Safety F. <br /> .' <br /> Alcohol and Gambling Enforcement <br /> Cedar Street.Suite 133 <br /> R} ^* <br /> St Paul MN 55101-5133 •� <br /> 65 1-296-6979. TTY 651-2$?-6555 e Fan 651-297-539 <br /> RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br /> No license will be 4ppmvrd or released untie the $20 Retailer ID Card fee is rCCCived by MN Liquor Control <br /> 1 : 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 Coldei M1=1n s e P e r i o d E n d i n g 1 P 1D# a563 <br /> City/County where license approved.Ro 5 e u 11 1 e <br /> Licensee Name Love From Minnesota Inc. <br /> Trade Name Love From Minnesota <br /> Licensed Location address 2465 Fairvi e w Ave N <br /> City. State,Zip Code Roseville, M N 5 5 1 1 3 <br /> Business Phone 651/639-1413 <br /> LICENSE FEES: Off Sale $0. 00 On Sale S 0 . 0 0 Sunday $ 0 . 0 0 <br /> By signing this 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 /> Auulicant's signature on this renewal confirms the following:Failure to report anv 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 citvlcounty <br /> where license is issued. $100,000 in cash or securities or$100,000 surety bond may be submitted in lieu of liquor <br /> liability. <br /> Licensee Signature Date <br /> (Signature certifies all above information to be correct and license 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 110 12.. J>Z. <br /> (Signature certifies licensee Or as ciates 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 9093-98 <br />