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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 /alcgamb /alcgamb.html <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee 5150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />Worker's Comp Ins. Co. 1.) 1' <br />L <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />yNC- 22- bi- ogyl:Y6 -0 e <br />Policy No. Policy Period •�i <br />City /County where permit approved: <br />Permit Name: <br />Trade Name: <br />Location address: <br />City, State, ZIP Code: <br />Business Phone: <br />13y 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 re )ort anv of the folios in' 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 have not been cited for any civil or criminal <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 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 all above information t4 }be correct and permit has been approved by city /countyh <br />City Clerk /County Auditor Signature Date <br />(Signature certifies that a consumption and display permit has been approved by the city /county as stated above.) <br />PS09097 ;01/001 mount Received <br />