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. ��,:,, Minnesota DeparE�ient of Public Safety <br />���.. ALCOHOL �z GA�D3�IlaTG �1��`Q12C�MENT DIVISION �;.2���.�'�''• <br />���: 444 Cedar St., Suite 133, St. Paul MN 55101-5133 ;���" � <br />� ° �6si� 296-6439 TTY �6si� Zs2-6sss ��; ,...�� <br />�{- �' www.d s stace.mn.us/atc arrablalc aznb.litrnl -}•�'�'sr �' <br />' v•,r•• P• b' g . yi •: •� <br />• :;�'-:,' <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $250 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />�.:?�?� <br />(;���r-��&n ���a'i��: :���i::R <br />IttFi[,I'i{r� �3i' l;�'�7.�„�rl;'a� •K���;=�'1 <br />��.�.� I''� '�'131iE 1 :� i"! i"� �� �' �� � ri i..17_ � � �• �. �::'� <br />�° �1 e?'•' 1 �'' " rr��� rr � A X" �'� 5� <br />�F��:�'���� <br />��' �A�i� �kTi� *r,�j3���5 <br />�lli��'� r��r�: n�i�'I' c:{�����''I, <br />�I'1 �� IGF? {'fl r4?I{� F'!�i �; EI.[}kk' <br />Warker's Con�p Ins. Co. �� ����+�'��� =} Policy No. Policy Period <br />CitylCounty where permit Approved: <br />Permit Name: <br />Trade Name: <br />Location address: <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 nuinbe�s. If changes have occurred during the past 12 <br />months, please give c�etails on the back of this renewal, tlien sign below. <br />+4pE1ti�:nit"�+*�]Y.lfYu+P. ni5litig �[�IE-in:�l �YrcdU_l��_�hl� ��[uw�iu��: F,��r�.� �ur+:[rut �� u�'nc� �olauti+aur}, tisillr�iu5ucs. <br />i:��I�I�'ti.�T.T ����fit1.'fj�� 'M�? 1� h�5 �°�'.°J I17t7 � I!tirLlfiC I]Ct'I7�' 'aj��:l�� f}_' 3CI�' ClC}'�L�}'r�115f�1i:'..���.`If5' I�} 1�C �'�IC :7f <br />Mir�tesota. If ever rejected, please give details on the bacic of this renewal, then sign below, <br />2. Applicant con�irtns 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 confirins that during the past five years it or its employees have not been cited for any civil or criminal <br />liquor law violations. If violalions have occurred, please give details on S11fi back of this renewal, then sign below. <br />4. Applicant confirms tl�a� Workers Compensation insurance is in effect for the full license period. <br />5_ Appticant confirnis, no club on-sale intoxicating liquor license is held <br />6. Applicant confirms business premises are separate from any other business esiabl'asilmez�t�. <br />L'� <br />Applicants Signature �a'��i���� Date �������, <br />(Signature certifies all above information lo be correct and permit bas beet7 approved by cilyicounty.) <br />City ClerklCouiity Auditor Date <br />(Signature certifies that a consumption and display permit has been approved by the citylcoui7t}r as stated above.) <br />P'J�.���� i�J �'�I <br />.A�1°1utt�lt R#-��i�'e�l <br />