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Minnesota Department of Public Safety <br /> X - . <br /> Alcohol and Gambling Enforcement <br /> 444 Cedar Street. Suite 133 <br /> ' - St Paul MN 55101-5133 ,. <br /> 65 I-296-6979 . TTY 65 I-232-6555 .F LLx 65 I-297-5259 <br /> RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br /> No license will be;ppraved or mleascd until the S20 Retailer ID Card fee is received by N'N Liquor Control <br /> :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. MOA.4MS. 3 to report any license <br /> cancellation. <br /> License Code M W N O N S R _ License Period Ending „m. 12/3 1/2002 1D# „ 7 9 5 <br /> City/County where license approved.Ro s e u i 1 1 e <br /> Licensee Name India Palace Inc. <br /> Trade Name India Palace <br /> Licensed Location address 2570 C l e v e l a n d Ave N <br /> City, State,Zip Code Roseville, MN 55113 <br /> Business Phone 651/631-1222 <br /> LICENSE FEES: Otf Sale $a' 00 On Sale S 1500.00 Sunday S 0 . 00 <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 /> Applicant-'s signature on this renewal confirms the followine: 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 citvleounty <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 � ( -- <br /> (Signature certifies licensee or assn sates hav 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 />