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Minnesota Department of Public Safety r <br /># ALCOHOL & GAMBLING ENFORCEMENT DIVISION r ` • ` . ' . r(2 . 444 cedar fit.. Suite 133. St. Pauti,MN 55101-5133 <br />(65 l ) 296 -6439 TTY (65 1 ) 282 -6555 a <br />- *�M-7-y www.dps_ state .mn.us /alegamb /alegamb.html ` <br />RENEWAL OF CONSUMPTION PTION & DISPLAY PERMIT <br />Permit Fee S 150 (Renewal Date: Apri l 1) <br />MAKE CHECKS PAYABLE To: ALCOHOL & GAMBLING ENFORCEMENT T DIVI ION <br />1285 PRIVATE <br />Nazareth Council Inc. <br />Knights of Columbus 4021 <br />2233 N Hamline Ave /Suite B -12 <br />Roseville MN 55113 -5010 <br />IF NAME AND ADDRW <br />SH0WNA=NMCXX=4M <br />MAKECHANMBELOW <br />Worker's Comp Ins. Co. lVe Policy No. _�_.. Policy Period <br />JF Cityf minty w -Here Permit apps -med <br />Permit Naine: <br />Trade ill ani e: <br />Location addressrt_�_��.__ g <br />C i ty. State, Zl P Code : _- 012 ev e 10,u, <br />B use nes,s Phone: �- 6 <br />By signing this renewal application. applicant certifies that there has been no chance in ownership, corporate c3fficers, <br />bylaws, membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12. <br />months, please rive details on the hack of this renewal, then sign below. <br />Applicant's signature on this renewal conrirms the followinin Failure to report any of the following will result in fines. <br />1. Applicant confirms that it has never had a liquor license rejected by any city/township /county in the state of <br />Minnesota. If ewer rejected, please give details on the back of this renewal, there sign below. <br />2— applicant confirms that for the past five years it has not had a liquor license revoked for any liquor law violation (state <br />of local). If a revocation has occurred. please give details on the hack of this renewal. then sign below. <br />3. Applicant confirms that during the past five years it or its employees have not been cited for any ci Sri l or cri m inal <br />liquor law violations. I f vio lat ions have occurred, please give details can back of this renewal, then sign below. <br />4. Applicant confirms that Workers Compensation insurance is in effect for the full license period. <br />5. Applicant confirms, no club can -sale intoxicating liquor license is held. <br />6. Applicant confirms business premises are separate from any other business establishment. <br />Applicant Signature )date <br />(Signature certifies all above information to be carnect and permit has been approved by city /county. ) <br />City Clerk/County Auditor Signature Date <br />(signature certifies that a consumption and display permit has been approved by the city /county as stated above.) <br />b <br />PS 09097 (01 /00) Amount Received <br />