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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 (6-1-2)- 222 -0484 <br />Ios-1 <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 L I ri-/ --e Cori Jo f$oC <br />Trade Name <br />Mailing Address SIC Li ±fff' C c/a 2°( 1, C. / ✓ ,SS// <br />Individual _Partnership _Corporation X Non - Profit _Other <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 Location(s) — List all Locations: <br />e 1. 57 4,i- tS'P c_n <br />Classification <br />Primary Nature of Business: <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. >SSpecial Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above '`%Z'- `Z- 1)n: <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 />Rt., d /Gril1-2L' <br />CVQ! .Uill/G 0.-L/144:/G.- A// <br />2. -9E7C cs i9 /5 <br />Page 27 <br />