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MINNESOTA JOINT UNDERWRITING ASSOCIATION PIONEER P.O. BOX 1760 ST. PAUL MN 55101 1- 800 - 552 -0013 651 -222 -0484 FAX: 651-222-7824 APPLICATION FOR LIQUOR LIABILITY COVERAGE Coverage will not be bound if the correct premium payment, written rejection or if quote exceeds 20% above plan rate, current license and required documentation of liquor receipts are not attached. Coverage cannot be bound prior to 12:01 a.m. the day following receipt of the above by the administrator. Legal Name of Applicant L,I9lete. i-Qnadci, t-Una�tCf +r »au< Tat'.. 6 TradeName(DBA) 0.vind1( ?lip DAy$ LL /� Mailing Address �7f5— « / �t° Rx / �/T''i c874 ,97� 55/I .� / /1�1C'�Gtt G,� Individual Partnership X. Corporation rc Non -Profit _ Other If Applicant is Individual: .// Applicant Name tV %3 If Applicant is a Partnership or Corporation: Name of each Partner or Owner Percentage of Ownership In Pi - f'esder4' Spouse Name Ai/ A - TbcePh E. 61i14.3 , (i 4<4<nk-a se(, `x'cireltr 1-v 41 i1R. 6eac4,610 i vi Operating Location(s) - List all locations: 5f00ner 1 I-- , Classification: Primary Nature of Business: I m I'Y! �d P1 ,117.1 1� esi LIIia,Y ? A r k , 350 E k i2/ . )i1H Cm /1 F-a.* 550-' Check all applicable: Restaurant Club Bar X. Special Event Bowling Alley *************** * * * * * * * * * * * * * * * * * * * * * * ** * * * * * ************ *** ** * * * ******** k***********%kip NOTE: OFF SALE FACILITIES MUST HAVE A SEPARATE ENTRANCE TO QUALIFY FOR AN OFF SALE RATE. Off Sale Only _LOn /Off Sales Total receipts of entire establishment: $ 7023,010. 1� g3 c7. 00 Gross receipts from Liquor Sales included above: $ Gross receipts from OFF SALE $ ON SALE: $ Seating Capacity: License in effect? Yes No Total W Bar Only Licensing Authority: h F c Address: ,�1 -r (“a <- kA. City: LIM... !.1„ iti t <;._ State: MN Zip Code: Fax #: (,,51- 1t4- 404 >';