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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 LZTTZL. CANAAA RLCREATasN ,4JSoCZATtO/v <br />Trade Name <br />Mailing Address f/3' E. hZT7J E GAi"»b,9 Ab A. [. MN ,f V/) <br />Individual _Partnership _Corporation ✓�1on- 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 />1.990 5 4.7.77 LE t.Q#,AAA ES 2. <br />Classification Z N <br />Primary, Nature of Business: ff{o�+n4TA: Y6N1 N :vim; l <br />).,ZTTLS. CAAJAAA <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. p/Special Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above it% SO a <br />Seating Capacity /SO Total Bar Only <br />License in Effect? Yes No ChM &IA G <br />Licensing Authority kin iA cAAJ4Ail <br />Address .r /S F AtTTLf_ PAriAAA 4. C. MA+ ,SS //7 <br />License Number <br />Effective Date / AW4 4 Expiration Date 1/21/41 <br />License Ever Revoked/Suspended. _Yes ✓ No If yes, date <br />If yes, explain <br />Page 60 <br />