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License/Permit Type: 2AM-500K+ <br />Permit Number: 25037 <br />DBA: Blue Heron Grill <br />Blue Heron Grill Inc. <br />14725 Victor Hugo Blvd <br />Hugo, MN 55038 <br />Business Location <br />14725 Victor Hugo Blvd <br />Hugo <br />Minnesota Department of Public Safety <br />Alcohol & Gambling Enforcement Division <br />445 Minnesota Street, 1600 <br />St Paul , Minnesota 55101 <br />651-201-7507 <br />Renewal for 2am License/Permit <br />Expiration Date: 5/16/2020 <br />Business Telephone: 6512607520 <br />If any of the above licensee information is not correct, please make corrections as necessary. <br />Licensee must report previous 12 month on sale alcoholic beverage gross receipts by checking one of the boxes below. Next to the box <br />you check is your 2 AM license fee. Make check payable to: Alcohol and Gambling Enforcement Division (AGED). Mail this application <br />and check to address listed below. <br />_ $300 2 AM license fee - Up to $100,000 in on sale gross receipts for alcoholic beverages <br />750 2 AM license fee - Over $100,000, but not over $500,000 in on sale gross receipts for alcoholic beverages <br />1000 2 AM license fee - Over $500,000 in on sale gross receipts for alcoholic beverages <br />200 2 AM license fee - 3.2% On Sale Malt Liquor licensees or Set Up license holders <br />$200 2 AM license fee - Did not sell alcoholic beverages for a full 12 months prior to this application <br />XYes _No Does the city or county that issues your liquor license allow the sale of alcoholic beverages until 2 AM? <br />City Clerk/County Auditor Signature_ Date <br />r <br />(I certify that the city or gpunty-�f flAr approves the sale of alcoholic beverages until 2AM) <br />�/ r'kV <br />Licensee Signatureve a tF <br />(I certify that hah a ve *quens truthfully and correctly) <br />Date �Zz ] <br />Licensee Minnesota Tax ID Number (Required): Qt 1 40_ NOT FEDERAL TAX ID <br />Licensee: Prior to submitting this application to the Alcohol & Gambling Enfocement Division you must <br />have this form signed by your local city or county licensing official <br />