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, <br />t�/Iirti�esota Depart�ner�t c�f PubIic Saf�ty <br />�"� &`�, .��.CO�OI, �4z (AFkI�$I�FN(B �ilil+�Y��'Eli��+�1� I]YVIS�OIV a4�'T�F°S i�'� <br />�� �`�.., �..�.e,.��;�.:.�r. <br />II���' 444 C`edar �t., Suite 133, St. Pa�l MN 55�.01-5133 ��"� � ��, <br />� (651} Z96-b439 �`TY {651) 282-b555 '�' :"�'�°�'�z�� <br />9�orhN�,F� www-dps.sCate.inn.usla[cgunbla�cgatnl�.httr�l ��.. �o <br />_, �.Rz * ;as�r��t�� <br />R�l�T��NAI. O�' C�3NSUlVII''�I�N 8z I3��PT,A�' I'�RIi�I'i <br />Pern�it �'ee $250 (Renewai Da.te: April ] ) <br />MAKE CHECKS 1Pt�YABL� TC3: A.LC�F��I, 8� �AMY3I,IIVG ENT������I�NT ��VISION <br />� :;. �_' ?::4 `:.'.� <br />��� �''i �: a .... ..:: f ` �ii'r �`.� k'� .... ..:� �.1. . � .... ... .,. .� s�s r <br />���pi ' .. �... .i_ �:: .;:: °, i " s r . ! -- �'!- jl =�' i <br />'�.i'tl �E :i. i..s`i 1:: :] E..; i.i. E_C�Y i:.) �..-'::F �,. t»,..�. <br />. : �•^ ' <br />� £..: ::.: •�. ; :'s �t�l �"'i t'�. �Fi �. :L ? i _.. �'°� `: F.'.- : ...t �.i. ... '�' �.: . • �i, a_.. <br />j-�c_ �'1 �sr i:� �. r ^: 'f � :a i`�� S`t �::.. �::.� R. ... .... ._s .'� �� i,ill <br />F._� 3-:' .f� =,1 f::� °j' �.. <br />Warke�•'s Corn In�. ec�:�,. �� � �' �� �G' � .... y No .� :;r . P�licy .Period. <br />� '�? � Polic <br />City/Cot�z�ty wl�ere peernit: �ppr€�ved: <br />Per�n�t Na�ue: <br />Trade Name: <br />Locatzo�x add�ess: <br />Ciry, State, 7TF Code: <br />�3usiz�ess Phone: <br />By signing ihis renewal applicaticm, agplicant cez-tifies i]�at tl�ez-e ]�as �een i►o cl�ange in t�wnetsbi�i, co�-pora€� o�ficers, <br />by]aws, nle�nbersiaip, �arci�ers, k�oa�xe addresses, c�r celepl�one nu�nb�rs. Tf chan�es have occ�rrec� during the past �2 <br />�na��ths, please give c�.eta�ls na1 tlae hack c�f tl�is renewat, tiae�� sig€� �eiow. <br />A. �icant's si atur�e nn this g•cai�wal ��a�tfkrrr�ts the ��llme�ve��e_�'aiia��-e ka� f•eprrri any of �l�e �'oDo��� avill result i�a fia�es. <br />1. Applicant coz�finns that it has never I�aci a liq�Qa' ].icense rejected by any city/towi�ship/counCy aa� the staie of <br />Minnesota. I€ a�rer rejected, please g�ve detaits oi� the back of tl�is rei�ewal, thei� sign betc�w. <br />2. Applicar�t co���irn�s that for the past five year it has uot �3ad a liquc�r license a'evnked fo�- any liquo�� [aw violatioza <br />(state or [oca]}. If a revncation l�as occurred, �lease give €�etails o� tlxe bac� of tllis rene�wa�, t�1�ert� si�n i3�ic�w. <br />3. Applicant cot��ir��3s tl�a[ durang the past five years ii c��� its e�7�lc>yees l�a�e ��ot been cited for any ci�il or crimi��a] <br />liquor law vioiations. If vic�latic�i�s have oceurreci, �lease give details ai� the back of iltis zeaaewal, tlaeaa si�i� belc�w. <br />4. Applicaz�t c�nfrms thae Vt�ot-1cez�s Cota�pe��sation insut-ance is in efFect for the fu]] lacca�,se �ae�°ioci. <br />S. Applic�z�t conf rms, no club on-sale i��toxicatii�g iic��io�- license is l�elcl <br />6. A.p��[icant cAt3firms busiiless p��e����ses a�•e se�arate fi�c�i3� ����y �3tl�er btasi�ess establasl�zx�en�. <br />Applicants Sig3�attirre ��'�'-e � Dafie t���l �.�- _ <br />(Signatur� certifies aII above iR�.formation to t�e co�•:-ect a��d �er�nic l��s i�e�a� appr�ved lZy city/ec�u7�ty.) <br />CiCy C1erk/Cc�ui�ty Auclitar �ate - - <br />(Sigi�ature certifies tltat a eo»sui�iptio» and dis�l��y �erinit l�as been appr€�ved by the city/coua�ty as statett above.) <br />P5�9097 coz�on� <br />