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Minnesotci Department of Public S-cifety <br />or P�j <br />k C01-10L & (7,AM'Bi'�'NG'ENFORC'IT..jkI.EN'T'DIVIS'��.'ON <br />MN 5 5 _10 1 -513 3 <br />444 Cedar St.. Suite 133., St. Paul. <br />(65 1) 201-7512 TTY 1(651) 282-6555 <br />I V <br />wxv-Al.dl)Sstaf,e.mii.us/alegamb/alcg�ainb.liti�iiI <br />RENEWAL OF CONSUMPTION DISPLAY PERMIT <br />Permit Fee $250 Re Vie" Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />D "J <br />V <br />5 1 1 <br />R I <br />.v <br />- ----- ------ <br />E NDI ADDRE <br />1F..-NAM A <br />Worker's Comp IDS. co <br />6 OA-P tc� e, Policy No,,,. Policy Perio d <br />City/County where permit Approved: <br />Permit Name: <br />Trade Name: <br />T ocation.,iddress: <br />City, State, ZIP Code: <br />Business Phone: <br />By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, <br />bylaws, membership, partners, home addresses, or telephone numbers, If changes have occurred during, the past 12 <br />I.F <br />months, please give details on the back of this renewal, then sign below. <br />Ap.p1j911t's siEiature on this renewal confinns the fopp"Lig.: Failtire to Le port miy of the f0Howm"gNvffl result M* ffies. <br />1. Applicant confirms that it has never had a liquor license rejected by any city/township/county in the state of <br />Mimiesota. If ever rejected, please give details on the back of this renewal,, then sign below. <br />2. Applicmit confirms that for the past five year 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 />3. Applicant 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 the back of' this renewal, then sign below. <br />f- I . <br />4- Applicant confirms that Wol-keLrs Cornpena-sation insurance IS I 1 11 effec[ for the full license p�ler-liold. <br />5. Applicant confirms, no club on-sale intoxicating liquor license is held <br />6. Applicant confirms business premises are separate from any other business establishment. <br />Applicants Signature Date <br />(Signature certifies all aboye info rniation to be correct and permit has been approved by citwciount�.) <br />City Clerk/County Auditor Date <br />(Signature certifies ,tfiat a consumption and display permit has been approved by the city/county as stated above.) <br />MIMI <br />