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0 Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite 133 St. Paul, MN 55101-5133 (0 <br />651-201-7507 - TrY 651-282-6555 - Fax 651-297-5259 <br />RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES <br />x <br />4 <br />-qe <br />5", 7 <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Cleric/Comity 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 License Period Ending 12 /",�.A, f 2 0 r2lbit 9094 <br />City/County where license approved. LA.ke Elito <br />Licensee Name 1Y1 to 1 .1'. rt e F11 o w <br />Trade Name <br />lylinnesata Machine Shed <br />Licensed Location address <br />*8515 Hudson Blvd <br />City, State, Zip Code <br />Laike Elinav ON 55042: <br />Business Phone <br />651 /735-743E, <br />LICENSE FEES: Off Sale $ On Sale $ Sunday $ <br />01. 911"D 150&. i7j@ <br />By signing this renewal application, 5pplicant certifies that there has bedit nb Z afift in ownership on the awdiFe harmed <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 any 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 lice 00)m cash or securities $ 1 <br />use is issued I . r 100 000 yb it may be submitted in lieu of liquor liabil- <br />OK f if sal re4 ris 8 li, sale, or $50,000 at off sale). <br />' a xem7 000 1 7tle in liabil- <br />ity. (3.2% liquor licensX9 <br />Licensee Siwunhirp. z Lat'- <br />(Signature certifies all above information to be cou(cct and license has been approved by city/county.) Vr %L�T-o <br />City CledclCciunty Auditor Si acme Date <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/comity as stated above.) <br />County Attorney Signature Date <br />County Board issued licenses only-.(Signatme ceitaes licensee <br />Police/Sheriff Signature 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 PS 9093-05 <br />2* // V / . . <br />