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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 2,72-73-1-41:_. rANAQA i2: r.;2r=Arrem AuocTTC0 <br />Trade Name <br />Mailing Address sic Y .2.7:77-4.;-- r,4,1/4/54 ,to 4 ,LC MA" SS // % <br />Individual Partnership Corporation /Non- Profit. Other <br />If Applicant is Individual: Spouse Name <br />Applicant Name <br />If Applicant is a Partnership of Corporation: <br />Name Ownership <br />Name of Each Partner or Owner <br />Operating Location(s) — List all Locations: <br />1. 4/410 1-7:774.1: CA/1/AAA RA 2. <br />L•L• mN 1/455"'i <br />Classification <br />Primary Nature of Business: 1,2oa TC Yo u / tL /-t c; y ✓ i i %r S <br />Check all applicable <br />1. Restaurant <br />4. Bowling alley <br />6. Off Sale Only <br />Total Gross Receipts <br />Gross Receipts from <br />2. Club <br />5. On /Off Sales <br />7. ✓ Special Event <br />of Entire Establishment <br />3 Bar <br />Liquor Sales Included Above <br />Seating Capacity /on Total <br />License in Effect? Yes No t'r.J d2Ai 4 <br />Licensing Authority ki: ibr (A,vAA4 //� <br />Address L C' 4 4 A A <br />License Number <br />Effective Date <br />License Ever Revo ed Suspended? _Yes ,/bto If yes, date <br />If yes, explain <br />Bar Only <br />Expiration Date <br />Page 46 <br />