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MINNESOTA JOINT UNDERWRITING ASSOrIkTION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1 -500- 552 -0013. OR (`6' -2) 222 -0484 <br />APPLICATION FOR LIQUOR LIABLITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written <br />required documentation of liquor receipts are not attached. Coverage <br />a.m. the day following receipt of the above by the Administrator_ <br />rejection, current license, and <br />cannot be bound prior to 12:01 <br />Legal Name of Applicant L/'11/v reed /, <br />Trade Name (-Ca- <br />Mailing Address .S iS - L/ "Hit' riat,, „ de, Kd , G / f tic: <br />Individual Parme:ship Corporation _Ligon-Profit <br />If Applicant is individual: <br />Applicant Name N /A- Spouse Name <br />If Applicant is a Parmership or Corporation: <br />Name of Each Palmer or Owner Percentage of Ownership <br />ILK - N/A <br />SLGiC' "it.ry <br />L,, J�+ gRilF% Trz,sores / <br />i5o G is l7 d» <br />C� <jz., frur%, 5570 <br />/ <br />Other <br />ry %9 <br />Operating Location(s) — List all Locations: <br />L .J/S C 2 d . 2. 3 r ,- t ii zK 331, c,/ K <br />Classification <br />Primary Nature of Business; <br />Check all applicable. <br />1. _Restaurant <br />4. _Bowling Alley <br />7. ,b Special Event <br />Re, tl - Ta:,.Lnry ate- 1- <br />2. Club 3. Bar <br />5, On/Off Sales 6. Off Sale Only <br />Total Gross Receipts of Entire Establishment '4' ou u — 3 00o <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity Total Bar Only <br />License in Effect? Yes No <br />Licensing Authority <br />Address <br />License Number <br />Effective Date Expiration Date <br />License Ever Revoked /Suspended? __Yes , No If yes, date <br />If yes, explain <br />S A H" L. <br />