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� a,,,�� Minnesota Department of Public Safety ALCOHOL & GAMBLING ENFORCEMENT DIVISION � 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 (65 1) 296-6439 TTY (65 1) 282-6555 " '�a� www.dps.state.mn.us/alcgamb/alcgamb.html � ��*.. . ' RENEWALOFCONSUMPTION&DISPLAYPERMIT Permit Fee $150 (Renewal Date: April 1) MAKECHECKSPAYABLETO: ALCOHOL & GAMBLING ENFORCEMENT DIVLSION 1285 Nazareth Council Inc. DBA Knighte of Columbus 4021 2555 N Snelling Ave Ros�ville �IN 55113 PRIVATE Worker's Comp Ins. Co. �i �....ws. �y r_. � Policy Na "'`-� ity/County where permit approved: y� p S�.y ��,�- �� Permit Name:^/'� Z A/? E' T�-f �a �tJ�° <<-- Trade Name: K�,� c� � � �, Location address: �,.�-r� �� City, State, ZIP Code: �a,sr �,` � a ,�,� Business Phone%'�� , � �- 3 � � ,g/FL - 7�O> Policy P � s.r • J _____ — _ _. By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, bylaws, membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give details on the back of this renewal, then sign below. A�nLicant's s mtatare on this renewel coc�ffrms the followia�: Failnre t� report ag� o! the followinQ wW result ;,, Bnes. � 1. Applicant confirms that it has never had a liquor license rejected by any city/township/county in the state of Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. � 2. Applicant confirms that for the past five years it has not had a liquor license revoked for any liquor law violation (state of local). If a revocation has occurred, please give details on the back of this renewal, then sign below. v 3. Applicant confirms that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations. If violations have occurred, please give details on back of this renewal, then sign beiow. ---- �. A p�3"i'ica�i t con-`f'�ms iCiai�Workers'Compensa[ion ins6rance is in� e`�i�ec��or t}ie�alITicense period. � , 3. Applicant confirms, no club on-sale intoxicating liquor license is held. � 6. Applicant confirms business premises are separate from any other business establishment. Applicant Signa Date ;, / �''�"• "' ��"'� � (Signature certifi all above infonnation to be correct and permit has been approved by city/county.) �City Clerk%County Auditor Signature Date (Signature certifies that a consumption and display permit has been approved by the city/county as stated above.) PS09097 (O1/00)