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06-28-22;09;27AM; <br />�1 <br />;6515782427 # 1/ 1 <br />AC R& CERTIFICATE OF LIABILITY INSURANCE <br />DATB(MMIDDIYYYY) <br />0612sr22 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder to an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, Certain policies may require an endorsement, A statement on <br />this cortlfleate does not Confer rights to the certificate holdor I n lieu of such endorsements , <br />PRODUCER <br />KIM L BROWN INC <br />PO Box 25407 <br />Woodbury, MN 55125 <br />CONYACY <br />NAME Kim L Brown <br />¢"o"E 651 73D- B03 aucN • 651 57B•2427 <br />Ea nlLs kIm klbins.com <br />INSUREn 151 AP FORDtNC COVERAOE <br />NAIC 0 <br />INSURER l Illinois Capgalt Company <br />ISM <br />INSURED <br />Maxx Bar & Grill <br />Maxx Bar & Grill Inc,Westy's Properties <br />17646 Central Ave NE <br />Ham Lake MN 55304 MN 55304 <br />INSURER 0 I <br />INSURER C I <br />INSURER D: <br />INaURERE; <br />INSURER F ; <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER' <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />INGR <br />TYPE OF IN6URANCE <br />ADDL, <br />SUS <br />POLICY NUMBHR <br />POLICYEFF <br />MMIODIYYYYI <br />POLICY EXP <br />fMM)0DNYYy1 <br />LIMITS <br />X. <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />EACH OCCURRENCE <br />S 100DOOD <br />PRE ISES(Ea o <br />$ 50 ODD <br />MED EXP (Any oneperson) <br />$ <br />PERSONAL & ADV INJURY <br />a 10000OD <br />A <br />BP43162 <br />07/01122 <br />07101/23 <br />GEN'LAGGREGATC LIMIT APPLIES PER: <br />POLICY PRO- <br />JECT L] LOC <br />ROTNER, <br />GENERAL AGGREGATE <br />S 2ODDODO <br />PRODUCTS•COMP/OP AGO <br />S 200DOOD <br />$ <br />AUTOMOBILE <br />LIABILITY <br />Ee MINED 51NGLE LIMIT(aKrifiprl I] <br />i <br />BODILY INJURY (Par parson) <br />$ <br />ANY AUTO <br />OWNED ASCHROVLEG <br />AUTOS ONLY AUTOS <br />HIREO NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />BODILY INJURY (Par eccldanl ) <br />$ <br />q E <br />Pere enl <br />$ <br />1 <br />UMBRELLA LIAO <br />H.CLAIMS-LADE <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAR <br />DIED I RE ENTION <br />s <br />A <br />WORKERS COMPENBAYION <br />AND EMPLOYERS' LIABILITY Y I N <br />ANY PRO PRIETOR/PARTNER/EXCCUTIVB <br />OFFICERIME NHj EXCLUDED? 71 <br />If e under <br />Yy <br />NIA <br />WC18068 <br />07/01/22 <br />07/01/23 <br />X T ERH <br />E.L. EACH ACCIDENT <br />$ 500,000 <br />E.L. DISEASE - EA EMPLOYE <br />S 500.000 <br />F.L. DISEASE • POLICY LIMIT <br />E 500QD <br />DESGt IIPTiON OF OPERATIONS below <br />A <br />Liquor Liability <br />L4106261 <br />07/01/22 <br />07101/23 <br />Occurence <br />$500,000 <br />Aggregate <br />unlimited <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remorke echodule, may bo attached If more @Paco is required) <br />Extends coverage to Festival in the Park August 20th, 2022, Coverage Is Continuous until Canceled, Coverage extends to all events <br />on and off promiso for food and liquor. <br />1.Gft I rrIWA I M MVLUCR <br />Attn: Katherine Smith <br />City of Mounds View <br />2401 Mounds View Blvd <br />Mounds Viow, MN 55112 <br />tbocklln@donnisklrk,com <br />Info@moundsvlewmn.org <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS, <br />AUTHORIZED REPRCSENTATNI! <br />O 1SBB•2015 ACORD CORPORATION. All rlahts rasorvod <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />