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Minnesota E)epaitment of Public Safety <br />ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />444 Cedar St., Suite 133, St. Paul. MN 55101-5133 <br />(612)296-6439 TTY(612) 282-6555 <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $150 (Renewal Date: April 1) — v <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />5590 <br />Navarre Lanes Inc. <br />Navarre Lanes <br />Box 51 <br />Navarre, MN 55392 <br />PUBLIC IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />Worker ’s Comp Ins. Co.Policy No.Policy Period <br />Citv/County where permit approved; C) R^C> fJf 7~^/ <br />Permit Name:aj <br />Trade Name: <br />Location address:(So y=- n <br />City, State. Zip Code:AOg )/j^ ff. fl ^ 9'*^ <br />RiKinpicc Phone!Y7/ -S'S'// <br />AppHcant Signature '1 <br />(Signature certifies all above information to be correct and permit has been approved by city/county. <br />ritv Clerk/Countv Auditor Sienattre Date <br />(Signature certifies that a consumption and display permit has been approved by the city/county as stated above). <br />By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers.bylaws, <br />memtership, 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 />ApDlicant's signature on thb renewal confirms the following! Failure to report anv of the following will result In <br />flnes. <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 emplo>ees have not been cited for any civil or criminal liquor <br />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 fuli license period. <br />5. Applicant confirms, no club on-sale intoxicating liquor license is held. <br />6. Applicant confirms businKs^remise^e separate from any other business establishment. <br />PS09097 (10/97)