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13uubdi nt ou 13 <br />��� Minnesota Department of Public 5afety �cK�.•q � <br />� Alcohol and Gambting Enforcement Division F `:� <br />,�oFU��. 444 Cedar St., Suite 222, St. Paul MN 55101 d� .._ -.-� <br />(651}201-7512 TTY(651)2&2-6555 y'r �.�� <br />www.dps. state.mn, uslalcgamblalcgamb.html <br />RENEWAL OF CONSUMPTIQN & DISPLAY PERMI'I' <br />Permit Fee $250 (RenewaE Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />��I��.��r�?�:h�r �;F��_�nc�i.l :G�ic�� <br />f�.r��_yf�ts c�f �al���I�E_t� 4���`1 <br />�:»i»»��:� � H�[II 1 1 i! t�' � a' � f��_t :L'� i� ��.__ �. �� <br />�"� t] 5 P'�a 1�. �. C� g ��� J J�. � j—.�.1 ��. 4:.� <br />Worker's Comp Ins. Co. <br />����� <br />City/CounEy where permit Approved: <br />Permit Narne: <br />Trade Name: <br />Location Address: <br />City, State, ZIP Code: <br />Business Phone: <br />�tF;NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT; <br />MAKE CHANGES BELOW <br />Po[icy No. PQlicy Perind <br />By signing this renewal appEication, applicant certif�es thaE there has been no change in owaership, corporate office��s, bylaws, <br />mem6ership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give <br />details on the back of this renewal, then sign below. <br />A.pplicants's signature on this renewaI confirms the following• Failure to report any oF the following will result in fiRes. <br />I. Applicant confirms that it has never had a iic�uor license r�jected by any city/township/county in the state of Minnesota. If <br />ever rejected, please give details on the bac[c of this renewal, then sign below. <br />2. App[icant confirms thai fox the past five years it has not had a liquor license revoked for any [iquor law violation (state or <br />[ocal). IF a revocation has occurred, p[ease give details on the back of this renewal, then sign below. <br />3. Applicant confir€ns that during the past five years it or its employees have nqt been cited for any ci�il or criminal liquor law <br />violations. If vialations have occurred, please give details on the back of this renewal, then sign below. <br />4. Applicant confrrms that Workers CompensaEion insurance is in eFfect for the full license period. <br />5. Appiicant confirms, no club pn-sale intoxicating liqaor license is held. <br />6. Applicant confirms business pr ises are separate from other business establishment. <br />� <br />Applicants Signat � Date � -�� � /� <br />� - <br />(Signature certifie bove information to orrect nd permit has been approved by citylcounty.} <br />City C1erklCounty Auditor Date <br />(Signature ceriifies that a consumption and display permit has been approved by the city/county as stated above.) <br />PS09�97 (o�roa> <br />mount Rece�ved ' � <br />