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LIQUOR CONTROL DIVISION <br /> ROOM 440 333 SIBLEY ST. <br /> ST. PAUL, MN 55101 <br /> PHONE 612.296-6159 <br /> <br />CERTIFICATION OF AN ON SALE AND/OR A SUNDAY LIQUOR LICENSE <br /> <br />IF NAME AND ADDRESS SHOWN A <br />NOT CORRECT. MAKE CHANGES <br />SPACES eELOW. <br /> <br /> ISSUING AUTHORFI'Y {Check only one) <br /> <br />CITYOF Ramse¥ COUNTYOF Anoka <br /> <br />UCENSEE hDkME ih~,JDiV1DUA.[., ~4~TNER~HIF0 ¢ORPORAI~ON~ ~D[ N~ ~ D~ <br />Diamonds Sports Bar & Grill Inc. D~amonds Sports Bar & Grill <br />~ ~D~ ~ ZIP <br />5566 K~owa S~reet NW Andover 5530~ <br />u~Ns;~ I~ o~ oR so~ ~ U~NSE ~mca ~ COU~ <br />O.~U~SE~,. J ON~,[$4,000.00 IsUNDAY MCgeE ~MB~ 'sUNDAY FEE ,200.00 IBUSINESs ~ONE : <br /> <br />~rv T,~,,~ ~her <br />~,a?~E~OFnCE~ NA~ <br />Garry Moreau <br /> <br />PARTNEP.'OFFICE R <br />Richard Boushek <br /> <br /> ADDRESS <br /> <br /> ] 3?,7 ~n'k"v'i ~,~ Why An~n . ~ <br />J ADDRESS ' ' <br />J3700 Roseberry Place Anoka, HN 55303 <br />I ADD, ss " <br />J15566 Kiowa St. NW. Andover, MN 5530 <br /> <br />The Ucensee must have one of the following: <br />CHECKONE <br />[] A, Uquor Usbil;W Insurance {Dram Shop; -- $50,000 per person: $100,000 more than one person; $10,000 <br /> property destruction; $ 50,000 and $100. OO0 for loss of means of support. A3-rACH "CERTIFICATE OF INSUR- <br /> ANCE'' TO THIS FORM <br /> OR <br />LJ 8. A Surety bond from a surety company with minimum coverages as specified above In A. <br /> <br />[] C..A cerfl'ficate from the State Treasurer lJ'tet the Ucensee has deposited with the State, Trust Funds having a <br /> market value of $100,0OO c~ $100,000 ~n cash or aecurlties~~-- <br /> <br />1 CF. ETIFY THAT THIS UCENSE WAS APPROVED IN AN OFFICIAL MEETING BY THE GOVERNING BODY OF THE CITY <br />OR COUNTY. <br /> <br />CrTY/COUNTY <br />SEAL <br /> <br />Given Under My Hand and the Corporate <br /> <br />Seal this day of <br /> <br />During the past license year has a summons been issued u.nder the Uquor Civil Uability <br />Law (DRAM SHOP)7 [] ~YES '["~ NO Ifyes, at~achacopyofthesummons. <br /> <br />COMPLETE THOSE ITEMS THAT APPLY <br />TRANSACTION TYPE ~ NDA/ {~ REVOKE/CANCEl. J DATES SUSPENSION <br />[3 RENEWAL 0 TP, AN~ER ~ :S~.N~ION J FROM TO <br /> <br />DATE OF REVOC. ATION/CANC~LLATION <br /> <br />~301~.$S C'H, AHGE FROM <br /> <br />TRANSFER OF 0~NERSHIP FROM (NAME AND ADDRESS} <br /> <br /> IMPORTANT NOTICE <br />ALL RETAIL LIQUOR LICENSEES MUST HAVE A CURRENT FEDERAL SPECIAL OCCUPATIONAL STAMR THIS STAMP IS ISSUED BY THE <br />BUREAU OF ALCOHOL FIREARMS AND 'I~)BACCO. FOR INFORMATION CALL 612-290-349& I <br /> <br /> <br />