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Minnesota Department of Public Safety <br />ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />444 Cedar St., Suite 133, St. Paul MN 55101 -5133 <br />(651) 296 -6439 TTY (651) 282 -6555 <br />www.dps.state.mn.us/alegambialcgamb.html <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $250 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />89 1='l.11`51_ 3: C <br />Ho <br />My Le I-1 C.` ii c., fi.+:,taw. nt <br />2900 Rice St 43 <br />Litt le Canada, <br />Worker's Comp Ins. Co, R ' e- <br />City /County where permit Approved: <br />11' NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT„ <br />MAKE CHANGES BELOW <br />MMAR-UOVOOI22.4±/ <br />Policy No Policy Perio <br />Permit Name: <br />Trade Name: <br />Location address: <br />City, State, ZIP Code: <br />Business Phone: <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 have occurred during the past 12 <br />months, please give details on the back of this renewal, then sign below. <br />Applicant's signature on this renewal confirms the following: Failure to report any 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 on the back of this renewal, then sign below. <br />2. Applicant confirms that for the past five year it has not had a liquor license revoked for any liquor law violation <br />(state or 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 have not been cited for any civil or criminal <br />liquor law violations. If violations have occurred, please give details on the 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 bus i as&premises are separate from any other business establishment. <br />Applicants Signature iii �{ h�— Date d Z2-730 (Signature certifies all above information to be co ect a � permit has been approved by city /county.) <br />City Clerk /County Auditor Date <br />(Signature certifies that a consumption and display permit has been approved by the city /county as stated above.) <br />PS09097 (num <br />Amount Received <br />