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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1- 800 -552 -0013. OR (6i 222 -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 />am. the day following receipt of the above by the dministmtor. <br />Legal Name of Applicant <br />Trade Name <br />Mailing Address 5/-5- . , L i -4 (e z i .A1/1/ <br />Individual _Partnership _Corporation Non -Profit <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />Tf Applicant is a Partnership or Corporation: <br />Name of Each Farmer or Owner Percentage of Ownership <br />55'(7 <br />_,Other <br />Operating Location(s) — List all Locations: <br />1. 01JL)L, PiOe / /a(( <br />Classification <br />Primary Nature of Business: <br />Check all applicable. <br />I. _Restaurant <br />4. Bowling Alley <br />7.ZSpecial Event <br />2. CJ' ,`'lrt/G/ f 1 / L 4.G4 Cie- -Qcl <br />c(/ <br />(r rf /�� <br />2. Club 3. Bar <br />5, On/Off Sales 6. Off Sale Only <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above <br />Sating Capacity Total Bar Only <br />License in Effect? Yes No <br />Licensing Authority vvlry T+'Q.T Pii, 1: % c <br />Address `Pi0 L cioi, S7 , s��t cot._ <br />License Number <br />Effective Dare <br />License Ever Revoked/Suspended? <br />If yes, explain <br />GI 06 <br />c'oethc)/ OtTv <br />Expiration Date <br />_Yes — No If yes, date <br />