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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL MN 55101 <br />1- 800 -552 -0013 651- 222 -0484 FAX: 651-222-7824 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written rejection or if quote exceeds 20% <br />above plan rate, current license and required documentation of liquor receipts are not attached. Coverage <br />cannot be bound prior to 12:0la.m. the day following receipt of the above by the administrator. <br />t <br />Legal Name of Applicant /J / i *f- fo_ La ri a-A- pit n a.i i an Da. s , rI G , <br />Trade Name (DBA) l_-G1 Y) a (i i a (/) 61 l� S j p 7 <br />Mailing Address 515 e L'/ (IC O ri dt 1<A Li]+( '.iG�ia4a, MA) .56P / <br />_ Individual Partnership Corporation _ Non - Profit Other <br />If Applicant is Individual: <br />Applicant Name NI/ R Spouse Name N/4 <br />If Applicant is a Partnership or Corporation: <br />Name of each Partner or Owner Percentage of Ownership <br />(Hart) 7o (re(1 , e?s?dtyli" /U/4 <br />Lynda ,,,,,ct,J per) , vice.Posidefrf- rvG <br />R-nne diniann tiOntrer Nm- <br />Ku NJFI- <br />Operating Location(s) — List all locations: <br />SQrnrter &hlc 350 E_h' 2i! L-/He C7114d4 -, Mid 55/17 <br />Check all applicable: <br />_ Restaurant _Bar /Club _Special Event Other <br />Licensing Authority information MUST be filled out completely. <br />Licensing Authority: C j 11 ITT Line CAM ad-A-- <br />Address: Si S F L ii-(r. C'avia). u (2A <br />City: L.ittit. ('ijyta ,,14 . State: MN Zip Code: I(7 <br />Fax #: 6.)751- 7 (r (? - '1095? <br />License in effect? Yes X No <br />License Number: Effective Date: Expiration Date <br />Has license ever been revoked / suspended? Yes )( No If Yes, list date and explanation: <br />RECEIPTS: <br />Total receipts of entire establishment: $ <br />Gross receipts from Liquor Sales included above: $ 7 4-09. )O <br />Off Sale Only On/Off Sales X On Sale Only <br />Liquor receipts: ON SALE: $ 1 :5, 44-04 (✓i✓ <br />OFF SALE: $ (Off sale totals only qualify ibr off <br />sale rate if there is a separate entrance from where the on sale liquor is sold) <br />