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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 boiind prior to <br />12:01 a.m. the day following receipt of the above by the <br />Administrator. <br />Legal Name of Applicant L TTLF C/lsv,44» g attn. 7x..1 AJSdabrsau <br />Trade Name <br />Mailing Address tit E 4.27741-if CAaA44 Itb LITT.td 6ANA0A MN <br />CS//7 <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. 0 4. A f lit E RAI t- A.: TT42 eM1"141 <br />YHo .E Alnnrx.8 CstNACA RO <br />Classification <br />Primary Nature of Business: PAOmaTr Yw Lt T/āœ“ 9C T Sāœ“ i7 S41 <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. pe Special Event <br />Total Gross Receipts of Entire Establishment 1a S 0 0 <br />Gross Receipts from Liquor Sales Included Above 1/r G G <br />Seating Capacity /0 0 Total Bar Only <br />License in Effect? Yes No QgNOTivr <br />Licensing Authority L=TT4t tA4,4E4 <br />Address r1C E 12.774.E CAS0A itb 4L nit, cc") <br />License N mber <br />Effective Date Expiration Date J/%414, <br />License Ever Revo ed /Suspended? ^Yes .-'No If yes, date <br />If yes, explain <br />Page 64 <br />