Laserfiche WebLink
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 LrTrAZ CANAaA R.eC+2EBir.to04 Airder,arrir. <br />Trade Name <br />Mailing Address .CIS 5 . bS T T I /' p4",4 4A )Q A .0 c. mr) S'SJI) <br />_Individual Partnership Corporation ✓6Ton- 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. iT ma" CNnJ'J SGNeoL. (WI 2. <br />./602/ s)cmENEmv LC S'Sii7 <br />Classification <br />Primary Nature of Business: PAbrndr Vntaiii Ae7rw27Sr"S rd 4.0 <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 "en 40 " /Set <br />Gross Receipts from Liquor Sales Included Above 'r3.s0 - 1/430 <br />Seating Capacity 02 0 0 ",i S G Total Bar Only <br />License in Effect? Yes No eitei law <br />Licensing Authority 4. ZTrZ c AA, AAA <br />Address L _ ► A. n. <br />License Number <br />Effective Date / 0 J,j 9 {' Expiration Date <br />License Ever Revoked /S spended? Yes ✓No If yes, ate <br />If yes, explain <br />Page 20 <br />