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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St., Suite 100 L, St. Paul, MN 55101 -2156 <br />(612)296 -6439 TTY(612)282 -6555 <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $150 (Renewal Date: April 1) <br />7035 <br />Little Canada Hall Inc. <br />Little Canada Hall <br />433 E Little Canada Rd <br />Little Canada, MN 55117 <br />PUBLIC <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />Workmens Comp Ins. Co. e 4 %5 .5 1;4- Policy No. o'f- OSSgvSi-O\ Policy Period /4A.7 - 924/9a <br />City /County where permit approved; <br />/ <br />Permit Name: �, a.c 73 �2t oK O,. ` (, <br />// <br />Trade Name: Z 4/..o. _ c-y , 4. �..r /�.p /J7, 2/i—" <br />Location address: 6/3 / G {f /e C i 4, 4�1,'Y�v- �%h . <br />City, State, Zip Code: /, 7/}4,, CT gcL 1 ^J 5'S-'/ ( <br />7 <br />Business Phone: 7' / � - Y $ q" Z % a- G <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 changes have occurred during the past 12 months, please <br />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 <br />fines. <br />1. Applicant confirms that it has never had a liquor license rejected by any city /township /county in 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 effect for the full license period. <br />5. Applicant confirms, no club on -sale intoxi ting liquor license is held. <br />6. Applicant confirms business premises areparate from any other business establishment. <br />Applicant Signature <br />(Signature certifies all abov <br />Date 34/? 7 <br />formation to be correct and permit has been approved by city /county. <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(8/95) <br />Page 5 <br />Amount Received <br />