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DEC -10 -98 THU 09:24 AM NES2 PRO -TEAM <br />FAX NO. 612 671 6008 <br />P. 04 <br />MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />' PIONEER P.O. BOX 17G0 <br />ST. PAVL, MN 55101 222 -0484 <br />1- 800 - 552 -0013 OR <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written <br />rejection, cutrent• license and repaired 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 417745 CAN448.21' Y t' 17, AI j: er& A.0 (ff 97tt Jv <br />Trade Name <br />Mailing Address S /,T g AS ?7zf' c.,thviitteLn.. .CG ,n," -.0 .C117 <br />_Individual Partnership Cprporation floe- Profit other <br />it Applicant is Individual: <br />Applicant Name . Spouse Name <br />if Applicant is a Partnership of Corporation: <br />Nano of Each Partner or Owner Percentage of Ownership <br />Operating Location(s) - List all Locations: <br />1. AIYs c X2?T.S cAt'AAN RD 2• <br />1. C Ana✓ 35//7 <br />Classification <br />Primary Nature of Business: 4N0 pgatu Lke Voter)/ AG7,7d2r,i..t.4 <br />Cho01C all applicable.. <br />1. Reotaurant 2. Club 3. uflar <br />4. "Bowling alley S. On /Off Sales <br />6. -Orr Sale Only 7. .,L / special Event <br />Total Gross Receipts of 'Entire Establishment 18.3do0 702000 <br />Gross Receipts from Liquor Sd1AS included Above <br />Seating capacity /a o Total /6 6 Bar Only <br />License in Effect? _Yes _ NO ratio rN <br />Licensing Authority bzT7a E CA. -AAA <br />Address . b LT__£/. r CAN $ AA fit 2C Mttl/ ‹...C/J7 <br />License NUM <br />Effective Date. Expiration Date <br />License Ever Revoked /Suspended? Yes to/No if yes, date <br />If yet, explain <br />Page 44 <br />