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��Y�fA�r Minnesota Department of Public 5afety _ <br />� ALCOHOL & GAMBLING ENFORCEMENT DIVISIOIY ,::pS:sHF�s; <br />°P 444 Cedar St., Suite 133, St. Paul, 1V1N SSEOi-5133 tf��~�'�'� '���"�`�;,. <br />� p (65 l) 20 l-75 ] 2 TTY {651 } 282-b555 ii� �"� �-�iz1:� <br />''�oK.,,��� www.dps.state.mn.us/alcgamb/alcgamb.html 4�� 1�����2�` <br />H'�+f95Q��1.;. <br />RENEWAL OF C4NSCJMPTION & DISPLAY PERMIT <br />Permit Fee $250 (�enewal Date: April 1) <br />MAKE GHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />J. c_ �F � <br />��.�; ';� :� Y' t�'1:, �'1 l s F:a '. �.1�1 �:� :i �. .F � ��' n <br />€� F i� i�7 h� 1 � f �>; � I. e_a �i L, E_E. =s �:�. i�� ��' 7. <br />�: i: � _�..'a %.� � �_�. IR .�. 3. Tl Fa (� `,f �? ; G;� F ! � {; i_� �� ,.... �. i-. <br />ri � 5 �? �,' 1 i �. �s q �'`� �� i"J � � �. •.✓" ��..�i � �,�1 <br />�'� ].'��j-�'�. <br />Worker's Comp Ins. Co,�� f_ rr��°�-��-�r� � Policy No..__ Policy Perio <br />�� <br />CitylCounty where perinit Approved: �`,� � � ��� <br />Perrtiit N�me: � <br />Trade Name: <br />Location address: <br />City, State, ZIP Code: <br />Business Phone: <br />.. •� � <br />By signing this renewal application, applicant certifies that there has been no change in ownership, corpora€e officers, <br />bylaws, membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 <br />months, please give deta�ls on the back of this renewal, then sign below. <br />A licant's si ture on thfs renewai confirms the %I�awin : Failure to t�e rt an of the followin will result in fines. <br />1. Appiicant conf�rn�s that it has never had a liquor license rejected by any cityltawnship/county in the state of <br />Minneso[a. if ever rejected, please give details an the back of this renewal, then sign below. <br />2. Applicant confirms that for the past five yeaz it has not had a]iquor license revoked for any li.quor 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 €he past five years it or its emp[oyees have not been cited for any civil or criminal <br />liquor law violations. If viplations have accurred, please give details on the back of this renewal, then sign below. <br />4. Applicant confirms that Workers Compensation insurance is in effect for the fiil] iicense period. <br />ApplicanE confirms, no club on-sale 'rnEOxicating liquor license is held <br />6. Applicant conf�rms business premises are separate from any other business estahlishment. <br />/` ;% <br />Applicants Signature ���>�" ' �� ��%9 Date �; `� '" s�` <br />(Signature certi�ies all abo�eint�tion to be correct and permit has been approved by 'ty7counry.) <br />City C1erklCounty .Auditor Date <br />(Signature certifies that a consunrtption and dispiay permit has been approved by the cirylcounty as stated above.) <br />PS09097 (0�100) <br />Amo�nt Received <br />