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JUL -03-97 THU 09:28 AM AMERICAN EXPRESS <br />FAX NO, 6126710402 P.03 <br />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 _J.3 7 77.-6 C 4w4 AA 2 E c2$ A^-a,I A f1'or7A7 .aorl <br />Trade Name <br />Mailing Address SJt S. .LI r LA tAnnA,o ReAg 1 r. Av .4's1.,7 <br />Individual Partnership _Corporation Le/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) - List all Locations: <br />1. SP6 sag 2 PA t? 2. <br />42.7f4x c9..,9.84 m^1 <br />Classification <br />Primary Nature of Business: f260na7L Yad%. Rd,-Sv.Z -f,:f <br />Check all. applicable. <br />1. Restaurant 2. Club 3. Bar <br />4. Bowling alley 5. On /Off Sales '- <br />6. _Off Sale Only 7. ',Special Event <br />Total Gross Receipts of Entire Establishment a Soo <br />Gross Receipts from Liquor Sales Included Above 02066 <br />Seating Capacity Total Bar Only <br />License in Effect? Yes VS* PL-..A ^' G <br />Licensing Authority � L774d cA,..AAA <br />Address S�_e P Cz;, CA.+AdA t L L Mi✓ SS ��? <br />License Number <br />Effective Date _- ��c��S Expiration nate f_____ 2 <br />License Ever Revoke / spended? Yes +/No If yes, ate <br />Ir Yes, explain <br />Page 13 <br />