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I <br />%,rz3 0, Policy No. <br />Worker's Comp Ins. Co. <br />City/County where pennit Approved: F <br />Policy Period <br />4. Applicant confirms that Workm Compensation <br />MINIM <br />® is in effect for the full license period. <br />5. Applicant confmns, 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� A-a 116- Date 7 <br />inform <br />(Signature certifies aJI above ation to be correct and pertfit has been approved by city/county.) <br />MOM pill 1 0 1 111! 1111111 ii�ii, <br />Date <br />r-S4 <br />ignature certffies that a consumption and display penmit has been approved by the city/county asstated above.'� <br />1� <br />5 <br />