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tvUNNESOTA JOINT UNDERWRITING XSSOCATION <br />'IONEER. P.O. BOX 1760 <br />ST_ PAUL, MN 55101 <br />1- 800 -557 -0013. OR. (ErYf'rn -0484 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the comma prtrniuma payment, written rejection, current license and <br />required doanneatatioa of liquor receipts are not morbid 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 lI tchek rd EDu14a0 BasS I <br />Trade Nemec 11a5S <br />Mailing Address "7 c2- E 13 a y R-+✓ S77, <br />Individual _Partnership _Corpotadon _,Nan. -Pro &' <br />If Applicant is Individual: Spouse Name <br />Applicant Name <br />If Applicant is a Partnership or Corporati <br />Name of Farh Farmer or Owns Percentage of Ownership <br />t-it"He Ca_n,,da f%ec4 4jsocattn. AJ T-ne <br />Operating Locations) — List. all. Location= <br />1. S -0oon44- P&rC L.G. /H,v• 5-S //2 Z. <br />Cast/Icarian <br />Primary Nature of Business: <br />CSecs ail applicable_ <br />I_ _Restaurant 2_ Qub 3. Bar <br />4. _Bowling Alley <br />5, On/Off Sales 6. Off Sale Only <br />7. lSSpeeciialEvent �� <br />Total Gross Receipts of Et a Establichrr•et <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity Total Bar Only <br />License in EIS ea? Yes Yo <br />;rents Authority <br />Address <br />License Number <br />Effective Dare Expiration Data <br />License Ever Revoked/Suspended? —Yes , No If yes, daze <br />If yes, explain <br />F.J n D j20. , s c r -Fo,^ yd v fL o & L,/4/r CaawI <br />Page 15 <br />