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�, Minnesota Department of Public Safety ��` ��• � <br />�,�" �� ALCOHOL& GAMBLING ENFORCEMENT DIVISION �y��"���""•. �. <br />444 Cedar St.. Suite 133, St. Paul, MN 55 lO1-5133 �`�.� ��°; <br />� (65 1) 296-6439 TTY (65 1) 282-6555 ,'� <br />� www.dps.state.mn.us/alcgamb/alcgamb.html � <br />q� '�i..���. <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />1285 <br />.- . <br />. <br />Nazareth Council Inc. <br />Knights o f C o 1 umb u s., a.� 2� <br />2233 Hamline Ave N�s���—�—�°� <br />Roseville, M N 55113�—Sd �� <br />Worker's Comp Ins. Co. %i�i� � st ��� Y�Policy No. <br />City/County where permit approved: �}�� s�� <br />Permit Name: �r�� � � � .� a ,� �,�� ,k 5 R� <br />Trade Name: �� �A��,�, <br />�s� (?. <br />Location address: � z.� �, w � �/�.yr�,�� <br />City, State. ZIP Code: ��,���� � � �, <br />Business Phone: ��r �. �',3-�( ��vs' 3 g� <br />cc� <br />� .,� <br />-5K <br />; �.�_� � �� <r ,� x.��: <br />, <br />, � <br />� _t �� � . <br />� a ��,< ,��� �� n ���s ��� �" ..: _� - . <br />Policy Period <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 numbers. If changes ha�e occurred during the past 12 <br />months, please give details on the back of this renewal, then sign below. <br />Annlicant's sienature on this renewal conf'irms the f'ollowine: Failure to reuort anv of' the f'ollowing will result in fines. <br />I. 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 on the back of this renewal, then sign below. <br />2. Applicant confirms that for the 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 on the back of this renewal, then sign below. <br />3. Applicant confirms that during the past five years it or its employees ha�e not been cited for any civil or criminal <br />liquor law violations. If violations ha�e 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 full license 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 establishment. <br />Applicant Signature � � Date % ^ � �^ '�°�'�' <br />(Signature certifies a 1 above information to be correct and p�ermit has been approved by city/county.?, s T��^� <br />X City Clerk/County Auditor Signature � <br />(Signature certifies that a consumption and <br />.. .�..�. <br />��c T�"� 3�3��i�vo 5/ <br />PS09097 (01/00) <br />Date �' � 5 ' b � <br />un�v_as stated above.) <br />.�do -._�,,�.,, 4�.'�{, <br />Amount Received <br />