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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement <br />444 Cedar Street, Suite 133 <br />cot 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 />I I 66b§ 48166N�{1014600&20- bm.CA' "a, -6kehilk1 <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 CIN66 License Period Ending 1c'�Iwt EVIOAV 2761. <br />City/County where license approved. L.ake 1c.'lvio <br />Licensee Name 3M CIub/st. palul Inc. <br />Trade Name <br />Tar-tian Park Restkui-ant <br />Licensed Location address <br />20th 1\1 <br />City, State, Zip Code <br />1-ake E;Jino, MN 551114'a"'. <br />Business Phone <br />65:1. /733 --- 0773 <br />LICENSE FEES: Off Sale $ On Sale $ Sunday $ <br />By signing this renewal applica'i'.1646plicamt certifies that there has bodIAR"(1,11fiAle in ownership on the at'U'leodai0d <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 confirrits 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 00 in cash or securities or $100,000 surety bond may he submitted in lieu of liquor liabil. <br />fly. (3.2% liquor licenses exempt it's s are less than $25,000 at on sale, or $50,000 at off sale). <br />Licenseesignau e Date 111K'Z'AA� <br />(Signature certifies all above info �NiAn� `rRe-Qrrrect and license has 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 Allolm" Signature Date <br />Potin1yBoard issued licenses Mace is for Hen <br />--- ----- licensee -- Tes <br />Police/Sheriff Signature Date <br />(Signature certifies licensee or associates have not been cited during the past five years for any state/local liquor law violations <br />(criminal/civil). Report violations on back, then sign here. <br />PS 9093-05 <br />