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Minnesota Department of Public Safety <br /> <br /> Alcohol and Gambling Enforcement <br /> 444 Cedar St., Suite 133 <br />St. Paul, MN 55101-5133 <br />612-296-6430 · TrY 612-282-6555 · FAX612-297-5259 <br /> <br /> RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />No license will be approved or released until the $20 Retailer ID Card fee is received by MN Liquor Control <br /> <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 <br />license period. City Clerk/County Auditor are also required by M.S. 340A.4.04 S. 3 to report any license <br />cancellation. <br /> <br />License Code [3N.~S License Period Ending O~,/30/1 qg,~ID # <br />City/County where license approved Ra tn s e y <br /> <br />R~09 <br /> <br />Licensee Name Holm's Super Bowl Inc. <br /> <br />TradeName Holm's Super- Bowl <br /> <br />Licensed Location address 6720 Ri yet'da 1 e Dr` <br /> <br />City, State, Zip Code Ramsey, MN 55303 <br /> <br />Business ['hone (612) 421-7779 <br /> <br />LICENSE FEES: Off Sale $ On Sale $ 4,000. O0 Sunday $ 200. O0 <br /> <br />By signing this renewal application, applicant certifies that there has been no change in ownership or the above named <br />licensee. For changes in ownership, the licensee named above, or for new licensees, full applications should be used. <br />See back of this application for further information needed to complete this renewal. <br /> <br />Applicant's signature on this renewal confirms the following: Failure to report any of the following will result in fines. <br /> <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 confunns that during the past license year, a summons has not been issued under the Liquor Liability Law <br /> (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 /> <br />Licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or securities or $100, 000 surety bond may be submitted in lieu of liquor <br />liability. <br /> <br />Licensee Signature Date <br /> <br />(Signature certifies all above information to be correct and license has been approved by city/county. <br /> <br />City Clerk/County Auditor Signature Date <br /> <br />(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above. <br /> <br />County Attorney Signature Date <br /> <br />County Board issued licenses only (Signature certifies licensee is eligible for license). <br /> <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 <br />violations (criminal/civil). Report violations on back, then sign here. <br /> PS 9093-98 <br /> <br /> <br />