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Minnesota Department of Public Safery �,� .. <br />��� ALCOHOL & GAMBLING ENFORCEMENT DIVISION rir�.' ��-� ;��. <br />'� � 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 '�'��.� � <br />�}�� �6si� 296-6439 rrY �6si� 2s2-6sss ;; �,�-� <br />www.dps.state.mn.us/alcgamU/alcgamb.htinl JY���-�',� <br />•u �• . <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />PermitFee $150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE T0: ALCOHOL & GAMBLING ENFORCEMENT I)��'$5���1 <br />'.��' � FRI Vf�l'E <br />IF NAME AND ADDRESS <br />�'� �� � �'' �' � k' � 4111 �� � � � R�' � SHOWNARE NOT CORRECT, <br />I:,� ��li �� o� Cu 1���+1�us �+C`:': MAKECHANGES BELOW <br />r�:• �� r�� ���,a�i� afl� �V���Ulvi� �° �� <br />• . . ti. - _ � � . , � •1'.� r� 1 _ � � _ .r��� _ � <br />Worker's Coinp Ins. Co.� r� ti�`��x ��• ��'� � Policy No. Policy Period <br />City/County where permit approved: ,,��,,,,,_ �� y' <br />I'e-i�� iR f� ��anr � � ir � t. +, <br />' - .. _ .._ .. � � r� � �� . . �. --��irvl ,r � � +Yrf � � <br />Trade Name: �� �' � � �L.� w � � � �. � � � t� r r- � ; -� <br />Location address: .;y �. 3 3 �} ��, , .�., i ; ne ,� - � z <br />Clty, St1t0, Z� COdO. � �' �'' � � � f � f$� rL'r .a � 1� � <br />� Il.kl �Iti:k� �r�lti�llti. �, •, r� • t• .� r ' �; f � r� � <br />� -- — -- — - - - - - - - — -- -- - -- -- -- -- -- - <br />By signing this renewal application, applicant certifies t11at 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 />months, please give details on the back of tliis renewal, tlien sigu below. <br />Applicant's siEnature on this renewal confirms the followin�: Failure to report au� of the following will result in fines. <br />1. Applicant confirms that it has never had a liquor license rejected by any city/township/county in the state of <br />Minnesota. If ever rejected, please give details o�� the back of this renewal, then sign below. <br />2. Applicant confirms tliat for tlie past five years it has not had a liquor license revoked for any liquor law violation (state <br />of local). If a revocation has occurred, please give details ou the bacic of tliis renewal, tlien sign below. <br />3. Applicant confirms that during the past five years it or its employees have not been cited for any civil or c�-in�inal <br />liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below. <br />4. Applicant confirms that Workers Compensation insurance is in effect for the fu113icense period. <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 establish�ne�it. <br />� � <br />Applicant Signature h��.'���� =�`f�"''r���r+�r,�_���er�.��f_.:�t-� r f�Y�y— L�SL� ,r� `��'f' f''� <br />(Signature certifies all above information to be correct and permit has been approved by cirylcounry.) <br />Ciry Clerk/County Auditor Signature Date <br />(Signature certifies that a consumption and display permit lias been approved by tlie cirylcounry as stated above.) <br />�50�� ��i:�:o�. <br />Amount Received <br />