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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, 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, 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 t- .ZTTl -t CAS 4t,4 R C-f %,t -'-dr- i9-!SocZATiro• <br />Trade Name <br />Mailing Address 51S g. LS i Tkr CA.vAAA _P 11 ,LITTLE C4,v4O4- dor <br />SS /i7 <br />_Individual _Partnership iCorporation 7/Non- Profit Other <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />Operating Location(s) <br />1. ?T3no642. P,4L( <br />029,S0 C a-A M t v 4 1 ,el) <br />Classification <br />Primary Nature of Business: <br />- List all Locations: <br />2 <br />L.C. SSii l <br />Pie0i41,,7r V0L4i// ACT:: li1tf <br />Check <br />1. <br />4. <br />6. <br />all applicable. <br />Restaurant <br />Bowling alley <br />Off Sale Only <br />Total <br />Gross <br />Gross Receipts <br />2. Club 3. Bar <br />5. On /Off Sales <br />7. '/ Special Event <br />of Entire Establishment 4'1o25oo <br />Receipts from Liquor <br />Sales Included Above <br />Seating Capacity <br />License in Effect? Yes <br />Licensing Authority 1.1r7LE r,Qn,AaA <br />Address Air L. - <br />License Number <br />Effective Date g If yes, date <br />License Ever Revo ed/ uspended. _Yes //N o Y <br />If yes, explain <br />Total <br />No Pb-N AI& 6 <br />Bar Only <br />Expiration Date /a40,7 <br />Page 153 <br />