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Minnesota Department of Public Safety <br />ALCOHOL & GAMBLINC ENFORCEMENT DIVISION <br />444 Cedar St, Suite 133, St. Paul. MN 55101 -5133 <br />(612)296.6 09 TTY(612) 2824555 <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $ 150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO; ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />7035 <br />Little Canada Hall Inc. <br />ATTN: Thomas 3. McDonough <br />433 E Little Canada Rd <br />Little Canada MN 55117 <br />PUBLIC <br />Worker's Comp Ins Co. <br />Policy No. <br />IF NAME 414b*St*E” <br />SHOWN ARE NOT COP.1 1, <br />MAKECHANCiE3SI . <br />sammussiatualasa <br />Policy Period <br />City/County where permit approved; <br />Permit Name: <br />Trade Name: <br />Location address: <br />City, State, Zip Code: <br />Bucinrc* Phone- <br />By signing this renewal application. applicant certifies that there has been no change in ownership, corporate officers,bylaws, <br />membership, partners, home addresses, or telephone numbers. if ahaugea'havo occurred during the past 12 months, please <br />give details on the hack of this renewal, then sign below. <br />Applicant's sionature on this renewal confirms the tbilowinr Failure to report any of the follow/Ina will result In <br />1. Applicant confirms that it has never had a liquor license rejected by any city/township /countyin the state of Minnesota. <br />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 />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 liquor <br />law violations. If violations have occurred, please give details on hack of this renewal, then sign below. <br />4, Applicant confirms that Workers Compensation insurance is in dia t no the full li zuse 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 S!¢natnre Dam <br />(Signature certftes all above information to be correct and permit has been approved by city/county, <br />City elerk/County Auditor Signature Date <br />(Signature cendfles that a consumption and displaypermit has been approved by the city /county as stated above). <br />PS09097 (10/97) <br />AMiwit0�IF!+1�N <br />• <br />Page 5 <br />