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PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1 -800- 552-0013 OR (61- 2)222 -0484 <br />I <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 />a.m. the day following receipt of the above by the Administrator. �{ <br />Legal Name of Applicant b Lt e. ative i Res a b01, / V ` , <br />Trade Name /� <br />Mailing AddressSlC /i #k CCaaS& eel 7 A' 6`5117 <br />_Individual _Partnership _Corporation XNon- Profit Oche: <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership or Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />Operating �La�c uuon(s) — List all Locations: <br />3r ohr� s �Jtm G.e 2. <br />Classification <br />Primary Nature of Business: giiddialty <br />Check all applicable. <br />1. Restaurant 2. _Club 3. Bar <br />4. Bowling Alley 5. On/Off Sales 6. _Off Sale Only <br />7., Special Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above 70 <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 />Page 49 <br />