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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite 133 <br />St. Paul, MN 55101-5133 <br />651-201-7507 - TTY 651-282-6555 - Fax 651-297-5259 <br />RENEWAL OF LIQUOR, WINE, , CLUB OR 3.2 % LICENSES <br />2 "oI . <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign, City <br />Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license <br />period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />cancellation. <br />License Code CIVIBL3 License Period Ending 12/-31/20 13V 2'7 6 0 <br />City/County where license approved. L�kke E'llao <br />Licensee Name Lake Elmo Inn Inc:. <br />Trade Name <br />L.�.Ake Elmo I ri n <br />Licensed Location address <br />3442'L,-xl<e E'Irso Av N/Pill Box :182 <br />City, State, Zip Code <br />L�Ake Elino, 1%11\1 55042 <br />Business Phone <br />651/777 ... ElLiS33 <br />LICENSE FEES: Off Sale $ On Sale $ Sunday <br />00 <br />By signing this renewal applicaium, "'PpReaut certifies that there has beeh no ntt�i in ownership on the al��Pd <br />licensee. For changes in ownership, the licensee named above, or for new licensees, full applications should be used. See <br />back of this application for further information needed to complete this renewal. <br />Applicant's signature on this renewal confirms the following: Failure to report gn-Y of the following will result in fines. <br />1. Licensee confirms it has no interest whatsoever, directly or indirectly in any other liquor establishments in <br />Minnesota. If so, give details on back of this application. <br />2. Licensee confirms that it has never had a liquor license rejected by any city/township/county in the state of <br />Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. <br />3: Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation <br />(state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. <br />4. Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal <br />liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below. <br />5. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability <br />Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below. <br />6. Licensee confirms that Workers Compensation insurance is in effect for the full license period. <br />Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or securities or $100,000 surety bond may be submitted in lien of liquor liabil- <br />ity. (3.2% liquor licenses are exempt if sales are less than $25,000 at on sale, or $50,000 at off sale). <br />Licensee. S "aturgO,44 EAA4,=_,e4 A -' 5-6, Da t, Zl-- 04- <br />(Signature certifieVall above information to be correct and license Qs been approved by city/county.) <br />City Clerk/County Auditor Signature Date <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above.) <br />County Attorney Siguature, Date <br />County Board issued llppnses only, (Signaturecertifies licenseeiseligible for. license), <br />Police/Sheriff Siguature Date <br />(Signature certifies licensee or associates have not been cited during the past five years for any statcAocal liquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br />PS 9093-05 <br />