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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. Jtec2AJZc+/ <br />Legal Name of Applicant 2777.1; CA.vA4A /?, CRrA77a. A <br />Trade Name <br />Mailing Address S/S ZTTir CANAAA R tx 2Z T2L CgN.,01/9 <br />it rs ,1 <br />_._Individual __Partnership _,Corporation ✓ on- 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. S Poo ^i 2 PMfX 1.7-77-21:: 2. <br />CANADA <br />Classification <br />Primary Nature of Business: laie6rnc re yo k 1 1/ /4C7- <✓ _77 t S <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 l iS'O G <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity <br />License in Effect? Yes <br />Licensing Authority A In-A; P qn. AQv4 <br />Address <br />License Number <br />Effective Date <br />License Ever Re <br />If yes, explain <br />Total <br />No I eN A S.v <br />Bar Only <br />vo <br />4.L .0 'N' .4 Z ♦ C. MN <br />�� 9� Expiration Date <br />ed Suspended? Yes ;/ No If yes, da e <br />Page 61 <br />