Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION444 Cedar St., Suite 222, St. Paul, MN 55101-5133 (651) 201-7507 FAX (651) 297-5259 TTY (651) 282-6555 RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license period. City Clerk/County Auditor is also required by M.S. 340A.404 S. 3 to report any license cancellation. License Code License Period Ending ID # City/County where license approved Licensee Name Trade Name Licensed Location address City, State, Zip Code Business Phone LICENSE FEES: Off Sale $ On Sale $ Sunday $ By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give details on the back of this renewal, then sign below. Applicant's signature on this renewal confirms the following: Failure to report any of the following will result in fines. 1. Licensee confirms that it has never had a liquor license rejected by any city/township/county in the state of Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. 2. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation (state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. 3. Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations. If violations have occurred, please give details on back of this renewal, and then sign below. 4. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below. 5. Licensee confirms that Workers Compensation insurance is in effect for the full license period. 6. Licensee confirms that it has no interest directly or indirectly in another liquor establishment, be it manufacture, distribution or retail, or if so give details on the back of this renewal. Licensee has attached a liquor liability insurance certificate that corresponds with the license period in the city/county where the license is issued. $100,000.00 in cash or securities or a $100,000.00 surety bond may be submitted in lieu of liquor liability Licensee SignatureDate (Signature certifies all above information to be correct and license has been approved by city/county. City Clerk/County Auditor SignatureDate (Signature certifies that an on-sale intoxicating liquor license has been approved by the city/county as stated above). County Attorney Signature Date County Board issued licenses only (Signature certifies licensee is eligible for license) Police/Sheriff Signature Date (Signature certifies licensee or associates have been checked for any state/local liquor law violations (criminal/civil) during the past five years. Report violations on back, and then sign here. A $30.00 service charge will be added to all dishonored checks. You may also be subjected to a civil penalty of $100.00 or 100% of the value of the check, whichever is greater, plus interest and attorneys fees. PS 9093-2009 No license will be approved or released until the $20 Retailer ID Card fee is received by MN Liquor Control American LegalNet, Inc. www.FormsWorkFlow.com Indicate below changes of corporate officers or partners, including: home addresses or telephone numbers. NOTE: Officers or partners may not be a person under 21 years of age. Report below, details of liquor law violations, both civil and criminal including dates and offenses, fines or other penalties; including Liquor Control penalties. NOTE: Incorrect or incomplete information is considered to be willfully fraudulent and is subject to legal recourse including fines and/or license suspension or revocation. Report below details involving any license rejections or revocations. NOTE: Incorrect or incomplete information is considered to be willfully fraudulent and is subject to legal recourse including fines and/or license suspension or revocation. City/County Comments: American LegalNet, Inc. www.FormsWorkFlow.com