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MINNESOTA JOINT UNDERWTRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1-500 -552 -0013. OR (� 2'22 -0484 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written rejection, current license, and <br />required documentation of liquor receipts are not attached. Coverage cannot be bound prior to 12:01 <br />urn. the day following receipt of the above by the Adrnin7suator_ <br />Legal Name of Applicant L • r� ,'e- Cont "'ck +tot /1-CSot! aiso.1 <br />Trade Name C 1'1. A <br />Mailing Address «7 E , la t.,74/4e._ P.A. 64 • stnv J5I /7 <br />Individual „Partnership ._._Corporation a..Non-Profit —Other <br />If Applicant is Individual: <br />Applicant Name N1/4- Spouse Name <br />If Applicant is a Partnership or Corporation: <br />Name of Each Palmer or Owner Percentage of Ownership <br />g - f tag ,deavt <br />Ada Suciu.. Seet,fmF-Y <br />tic...c.j K4SW'etar - - tteacoce(` <br />Operating Location(s) — List all Locaddns: <br />1. Sts- C 4tifite �4„ e <br />Classification <br />NiS <br />2. 5{'vok..cr ■e 3 -° Eli Qd <br />4c. Ow .J Sch1 <br />Primary Nature of Business: <br />Check all applicable. <br />1. _Restattrant 2. 3. 13ar <br />4. Bowling Alley 5 On/Off Sales 6. Off Sala Only <br />7. 4tSpecial Event <br />Total. Gross Receipts of Entire Establishment <br />--310 oo. oa <br />Gross Receipts from Liquor Sales Included Above goat— <br />Seating Capacity Total Ear Only <br />License in Effect? Yes No <br />Licensing Authority <br />Address <br />License Number <br />Effective Date Expiration Date <br />License Ever Revoked /Susperuied9 ___.Yes No If yes, date <br />If yes, explain <br />3 <br />