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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 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 A S I ' � ; C / a ,e A M R e _ T 2 v "v A J -f o c A i :-4/4` <br />Trade Name <br />Mailing Address .SiS A . y 7 72 r CANA AA g 4 4 17 7-!. C. CA a-A a A <br />'n N S'S /J 7 <br />_Individual Partnership _Corporation i/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 />1. n-e410a:+ r. _ .. *erg' I S ? o o /v f_ Z PM? K <br />• <br />.7 1.777A.C. CANAaA- m/V SS/i"T <br />Classincation <br />Primary Nature of Business: <br />Check all applicable. <br />1. Restaurant 2. _Club 3. _Baz <br />4. Bowling Alley <br />7. "/Special Event <br />Total Gross Receipts of Entire Establishment / co a -4; 0 00 <br />Gross Receipts from Liquor Sales Included Above `q /70 a• — s02aP0d <br />5. _On/Off Sales 6. _Off Sale Only <br />Seating Capacity Total Bar Only <br />License in. Effect? Yes No ti <br />Licensing Authority h 4. F T k C C: A/u A AA <br />Address Sir C .(.FTTLJ CAA. AAA R.a 1-C iiT <br />License Number <br />Effective Date 9) F/ 9 Expiration Date t/ %l 9 q. <br />License Ever Revoked /Suspended? _Yes >INo If yes, date <br />If yes, explain <br />Page 5 <br />