06/12/1995 Council Packet - Laserfiche WebLink

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Minnesota Department of Public Safety LIQUOR CONTROL DIVISION 190 5th St. E., Suite 105, St. Paul, MN 55101 (612)296-6430 TTY(612)282-6555 RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE No license will be approved or released tmttl the $20 Retailer ID Card fee is received by MN Liquor Control Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any license cancellation. License Code License Period Ending 6/30/9 6 City/County where license approved CITY OF LINO LAKES Licensee Name Jim and Ann Miller, Inc. Trade Name Miller's on Main Licensed Location address 8001 Lake Drive City, State, Zip Code Lino Lakes, Mn. 55014 Business Phone 783-7106 LICENSE FEES: Off Sale $ 100.00 On Sale $ 3 , 000.00 ID # 4225403 Sunday $ 200.00 By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give details on the back of this renewal, then sign below. Applicant's signature on this renewal confirms the following: Failure to report any of the following will result in fines. 1. Licensee confums that it has never had a liquor license rejected by 'any city/township/county in the state of Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. 2. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation (state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. 3. Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below. 4. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below. 5. Licensee confirms that Workers Compensation insurance is in effect for the full license period. Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county where license is issued. 5100,000 in cash or securities or 5100,000 surety bond may be submitted in lieu of liquor liability. Licensee Signature (Signature certifies a Date 57.z1/%J ve information to be correct and license has been approved by city/county. City Clerk/County Auditor Signature Date (Signature certifies that an on -sale intoxicating liquor license has been approved by the city/county as stated above). County Attorney Signature Date County Board issued licenses only (Signature certifies licensee is eligible for license) Police/Sheriff Signature Date (Signature certifies licensee or associates have not been cited during the past five years for any state/local liquor law violations (criminal/civil). Report violations on back, then sign here. PS 9093-94