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PHONE 16121296 -6430 <br />MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIVISION <br />ST. PAUL, MN 55101 <br />Tenn PSR/917 <br />CERTIFICATION LIE NC <br />ON SALE AND /OR A-SUNDAY-LIQUOR LICENSE <br />CITY CLERK MUST COMPLETE <br />'LICENSEE NAME <br />St. John's Church of Little Canada <br />TRADE NAME OR OBA <br />BUSINESS ADDRESS <br />380 Little Canada Road <br />CITY <br />Little Canada <br />ZIP <br />55117 <br />LICENSE TYPE (CHECK ONE OR BOTH) <br />OWN SALE a SUNDAY <br />LICENSE PERIOD <br />FROM 9 -30 -90 to 9 -30 -90 <br />COUNTY <br />Ramsey <br />ON SALE LICENSE NO <br />ON SALE FEE <br />SUNDAY LICENSE NO. <br />SUNDAY FEE <br />BUSINESS PHONE <br />484 -2708 <br />If a Partnership, State the Name and Address of Each Partner; If a Corporation, State the Name and Address of Each Officer. <br />PARTNER /OFFICER NAME <br />Rev. Robert J. Fitzpatrick <br />ADDRESS <br />380 Little Canada Road <br />PARTNER /OFFICER NAME <br />ADDRESS <br />PARTNER /OFFICER NAME <br />ADDRESS <br />The <br />CHECK <br />Licensee must have one of the following: (The type and amount to be determined by the City Council) <br />ONE <br />1. Corporate Security Bond ($3,000 to $5,000) <br />OR <br />E <br />2. Cash ($3000 to $5000) OR <br />NAME OF BONDING COMPANY AND AMOUNT <br />3. U.S. Gov't Bond ($3000 to $5000) <br />AMOUNT AMOUNT <br />CHECK <br />The <br />OR <br />_ <br />OR <br />flC. <br />Licensee must have one of the following: <br />ONE <br />A. "Certificate of Insurance" — $ 50,000 per person; $100,000 more than one person; $10,000 property destruction; <br />$50,000 and $ 100,000 for loss of means of support. ATTACH "CERTIFICATE OF INSURANCE" TO THIS FORM <br />B. A Liquor Liability bond from a surety company with minimum coverages as specified abo'$e in A. <br />A certificate from the State Treasurer that the Licensee has deposited with the State Trust Funds having a <br />market value of $ 100,000 or $100,000 in cash or securities. <br />Given Under My Hand and the City Corporate <br />CITY Seal this day of 19 <br />SEAL <br />Clerk and /or Recorder <br />During the past license year has a summons been issued �under the Liquor Civil Liability <br />Law (DRAM SHOP) (M.S. 304 A. 802)7 Li YES 1 I NO If yes, attach a copy of the summons. <br />TRANSACTION TYPE 0 NEW ❑ REVOKE /CANCEL <br />❑ RENEWAL ❑ TRANSFER ❑ SUSPENSION <br />DATES SUSPENSION <br />FROM TO <br />DATE OF REVOCATION /CANCELLATION <br />ADDRESS CHANGE FROM <br />TRANSFER OF OWNERSHIP FROM (NAME AND ADDRESS) <br />Illilly FOR OFFICE USE ONLY <br />CODE <br />FEES <br />A 8 C <br />MAILING ADDRESS <br />PS 9011 (3/86) <br />Page 41 <br />