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Minnesota Department of Public Safety <br />r <br />t {` A1colial and Gambling Enforcement <br />444 Cedar Street. Suite 133_ . <br />St. Paul, MN 55101-5133 � <br />651- 296 -6979 ' TTY 651-2$2 -6555 ! Fax 651 -297 -559 <br />RENEWAL OF LIQUOR7 WINE, OR CLUB LICENSE <br />No license will be approved or released until Lhe $20 retailer ID Card fcc is eived by MN Ligucr Control <br />Licensee- 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 liabilit a ror �w <br />license period. City Clerk/County Auditor are also required b M.S. 340A.404 � y the ne <br />cancellation, <br />9 y S. � to report ally license <br />License Code DNSS License Period Ending 12131 12003 ID# <br />City /County where license approved.R e s e v i 1 1 e � <br />Licensee blame Pav l i c k Holding Co, <br />Trade Name 01 Mexico <br />Licensed Locdation address 1754 N Lexington Ave <br />City. S Cate, Zip Code Roseville, 55113 <br />B us i Mess Phone G51/487-2847 <br />3406 <br />LICENSE FEES: Off Sale S 0,00 On 7000, 00 200,00 <br />� dale � Sunday � <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 Mons sltouirl <br />be used. See back of this application for further information needed to complete this renewal. <br />Applicant's .si nature on this renewal confirms the follovi n : Failure to re cart any or the rollo win gy will result in fines. <br />Licensee confirms it has no iliterest whatsoever, directly or i ndirec dy in any other liquor uor es tats li- idinie nts in <br />M i llileso ta. If so, give details oil back of this applica [ion. 1 <br />?. Licensee con # it -nis that it has sever had a liquor license rejected by aLly city /towilsiliplcoutxty in flit state of <br />1rI inIICSOtti. If ever rejected, please give details an the back of this renewal * then sign below. <br />3. Licensee cull[i mis Ehat for the p�a 5 t live ye al ;� it has not had a ligtl or license revoke ,'d for an liquor law violation <br />(str►te or local). I f a revocation has occuiTed, please give details on the back of this re Mlewa y , tl�et� -sign below. <br />4. Licensee con firms Chat during tlic past five ve years it or its employees liave not been cited For any civil ar cri iii iii a 1 <br />liquor 1,aw violations. If violations 13 ave occurred, please give details on hack of this renewal fl en . g <br />5. Licensee confirms tliaC during � �i �n - l�c..low, <br />Elie past license year, 21 slinitrtons has tint been issued under the Liquor Liability <br />Law (Drain Shop) NIS 340A.802. If yes, attacli a copy of the summons. then sign below. <br />6. Licensee conhrtlls l liat Work-cis Compensation insurance is in effect for the full license p eriod . <br />r- <br />Licensee has attached �tuolinbif ie irr insuranc certificate that corresponds with the li L <br />cLinse period i n cl t} ko unty <br />where license is issu i. 100 006,,ii 0 � ' . <br />hi a m, 111, ash car ec rite �r �• l ;o it surety board may be suhni tled in lieu of liquor <br />//_ Licensee S i onature rate <br />(Signature certi ["ies all at i ttforMation to be correct and license has been approved by city1coun t . <br />City Clerk/County Auditor Signatory )date <br />(Signature certi f es that rznewal of a liquor, wine or club license has been approved b the c it rlcou lit r as � <br />y stated abO e.) <br />COLT my Attorney SignMUM late <br />CoLI my Board issued licenses 0111y (S igitature eertif ies licensee is eligible for license). <br />Police /Sheriff Signature Date <br />(Signature certifies licellsee or associates leave not been cited during the [last G��e rea' rs for ally state local <br />(crinumillc Ivil). Rel�on violations on back, then sign Here. � � liquor law �ric�ltlti��ns <br />PS 093 -98 <br />