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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 (612) 222 -0484 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written <br />rejection, current license and required documentation of liquor <br />receipts are not attached. Coverage cannot be bound prior to <br />12:01 a.m. the day following receipt of the above by the <br />Administrator. <br />Legal Name of Applicant 4,:t7-74.L. C,9,J,96i9 /}Jfccra; ya)., <br />Trade Name <br />Mailing Address ,S /_s" E Lit74A= em P &B AD AC /NN rS7/7 <br />_Individual _Partnership _Corporation on- Profit _Other <br />If Applicant is Individual: <br />Applicant Name <br />Spouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />Operating Location(s) - List all Locations: <br />1. JeQONF 2 pAex L .C. 2. <br />Classification <br />Primary Nature of Business: Pio s». 7€ Ye 1‘.7,/ ,9c7 7 LCf <br />Check all applicable. <br />1. Restaurant <br />4. __Bowling alley <br />6. Off Sale Only <br />2. Club <br />5. On /Off Sales <br />7. iApecial Event <br />3. Bar <br />Total Gross Receipts of Entire Establishment 71 o2,5'sa <br />Gross Receipts from Liquor Sales Included Above ./ o2S s C <br />Seating Capacity Total Bar Only <br />License in Effect? Yes <br />Licensing Authority C t TY <br />Address Cir £ A2274' <br />License Nomher <br />Effective Date <br />License Ever Revokes/8 seen <br />If yes, explain <br />No PiN D.iN <br />al' _..1C2. 74,C CgNF/1.1,9 <br />cdNii'b •4 b .L, C Ss-J7) <br />Expiration Date <br />ded? Yes 1/No If yes, to <br />PAGE 165 <br />