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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 4.77771:: CA,JAAA /?r c,2 i47 7u,) 44-100-47-270,,l <br />Trade Name <br />Mailing Address S/S 0. L1 %72L CANA0.9 ?oAA 2Tr7L2 CANAAA ma/ <br />SSn� <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. SPocN2.f P/RX L7r74/E CA4At)92. <br />Classification <br />Primary Nature of Business: P20/1-76 71z: Yo-T/ 1C7 7 ✓ 2-7 Yy-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 4‘/..5-0 O <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity Total Bar only <br />License in Effect? Yes <br />Licensing Authority t. y ; ; ki <br />Address - ; AA," 44 <br />License Number <br />Effective Date Ql /e /9 y <br />License Ever Revoked /Suspended? <br />Yes /No If yes, date <br />If yes, explain <br />No pEN Der 6 <br />CANA11A <br />C A,' <br />Expiration Date 17/224//y_______ <br />Page 12 <br />