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Renewal Application for Optional Liquor 2AM License 6 Alcohol & Gambling Enforcement License Type: 2AM-500K+ Expires On: May 16, 2017 Blue Heron Grill Inc. Blue Heron Grill 14725 Victor Hugo Blvd Hugo MN 55038 ID Number: 25038 Business Phone: 6512607520 If any of the above licensee information is not correct, please make corrections as necessary. Licensee must report previous 12 month on sale alcoholic beverage gross receipts by checking one ofthe boxes below. Next to the box you check is your 2 AM license fee. Make check payable to: Alcohol and Gambling Enforcement Division (AGED). Mail this application and check to: AGED, 445 Minnesota St., Suite 222, St. Paul, MN 55101-5133. _ $300 2AM license fee - Up to $100,000 in on sale gross receipts for alcoholic beverages $750 2AM license fee - Over $100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages _$1000 2AM license fee - Over $500,000 in on sale gross receipts for alcoholic beverages _ $200 2AM license fee - 3.2% On Sale Malt Liquor licensees or Set Up license holders _ $200 2 AM license fee - Did not sell alcoholic beverages for a full 12 months prior to this application - Yes No Does the city or county that issues your liquor license allow the sale of alcoholic beverages until 2 AM? City Clerk/County Auditor Signature Date (I certify that the city or Qaunty of approves the sale of alcoholic beverages until 2AM) i'111 � Licensee Signature Date (I certify that I have answers a abov uesti ns truthfully and correctly) Licensee Minnesota Tax ID Number (Required): O QpIL/m Licensee: Prior to submitting this application to the Alcohol & Gambling Enforcement Division you must have this form signed by your local city or county licensing official Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division (AGED) 445 MinnesotaStreet, Suite 222, St. Paul, MN 55101-5133 Telephone 651-201-7500 Fax 651-297-5259 TTY 651-282-6555 dps.mn.gov