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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 A57 74.6 CA ,QA4A ,?EciacAc:orN /3SIocyri Ian <br />Trade Name <br />Mailing Address SAC r LXTi cc C J.vA an ,Z O ,1-T7 L E C,4N ,l.'4A nnj <br />S5a7 <br />Individual Partnership Corporation (/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. (cH mcmL :4,1 *,n7 AC- Cri/72. <br />ST 5d/•Is,/'r SCHooL. G`^z <br />Classification <br />Primary Nature of Business: PRomaZ2 YoH;H Ac- rvzriS iN torte CA.414. <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. L.--Special Event <br />Total Gross Receipts of Entire Establishment <br />/700 -do <br />Bar Only <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity 2 oo Total 070o <br />License in Effect? Yes No P6r 1)-ti,' <br />Licensing Authority . i i T� C n A.J4 4 A <br />Address s- j .c ;'4r C t ae A <C ^1A, S i7 <br />License Number <br />Effective Date /d/ar /9 7 <br />License Ever Revoked /S spended? Yes v No If yes, date <br />If yes, explain <br />Expiration Date /(f)/0.7..5/97 <br />Page 66 <br />