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PS gou (tt-891 <br /> <br />MINNESOTA DEPARTMENT OF PUBLIC SAFETY I <br />LIQUOR CONTROL DIVISION <br /> <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 ANO ADDRESS SHOWN ARE <br />NOT CORRECT. MAKE CHANGES IN <br />SPACES BELOW, <br /> <br /> ISSUING AUTHORITY (Check only one) <br /> <br /> CITY OF i'/~o_ v-¢3_%'~\I COUNTY OF ~ " <br />L~CENSEE NAME II .NDIVIDUAL, PARTNERSHIP, COR~RATtONI ~ TRAOE NAME OR DBA <br /> <br />UCENSE ~ ICHECK ONE OR BOTH) ] U~ENSE ~RIOO ' <br /> <br /> If ~ Pa~rship, State 1~ Name and Address o¢ Each Pa~er: If a Cot~radon, State the Name a~ Add,ess of Each Officer. <br /> <br />ADDRESS <br /> <br />ADDRESS <br /> <br />The Licensee must have one of the following: <br /> <br />CHECK ONE <br /> . <br /> A. Liquor Liabiliw Insurance (Dram Shop) -- $50,000 per person; $100,000 more than one person; $10,000 <br /> <br />OR <br /> <br />properly destruction; t~ 50,O00 and $100,000 for loss of means of support. ATTACH "CERTIFICATE OF INSUR- <br />ANCE'' TO THIS FORM <br /> <br />B. A Surety bond from a surety company with minimum coverages as specified above in A. <br /> <br />C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having a <br /> market value of $1 OO,000 or $100,000 in cash or securities. <br /> <br />I CERTIFY THAT THIS LICENSE WAS APPROVED IN AN OFFICIAL MEETING BY THE GOVERNING BODY OF THE CITY <br />OR COUNTY. <br /> <br />Given Under My Hand and the Corporate <br /> <br />Sealthis dayof <br /> <br />CITY/COUNTY <br />SEAL <br /> <br />During the past license year has a summons been issued under the Liquor Civil [Jabiliw <br />Law (DRAM SHOP)? [] YES [] NO Ifyes, attach a copy ofthe summons. <br /> <br />COMPLETE THOSE ITEMS THAT APPLY <br />TR~NSACTION'i-YPE ~ NEW O REVOI(~CANCEL [ DATES SUSPENSION <br />I~1 RENEWAL O TRANSFER I~ SUSPENSION I FROM TO <br /> <br />DATE OF REVOCATION/CANCELLATION <br /> <br />TRANSFER OF OWNERSHIP FROM INAME AND ADDRESSI <br /> <br />IADDRESS CHANGE FROM <br /> <br />19 <br /> <br />IMPORTANT NOTICE <br /> <br />I <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />! <br /> <br />! <br /> <br />I <br />! <br /> <br /> <br />