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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 />5598 PUBLIC <br />Navarre Lanes Inc. <br />Navarre Lanes <br />Box 51 <br />Navarre, MN 55392 <br />h <br />Workmens Comp Ins. Co. <br />City/County w here permit approved; <br />IF NAME. ND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />Policy Period. <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,bylaw'S, <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 anv 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 >ea'-s 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 >ears 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 full license period. <br />5. Applicant confirms, no clubpn-salc intoxicating liquor license is held. <br />6. Applicant confirms businie^ p/emisA are ^parate from any other business establishment. <br />Applicant Signature <br />(Signature certifies all abo/e informaifon to be correct and permit has been approved by city/county. <br />City Clerk/Countv Auditor Signature <br />(Signature certifies tl it)a|consuO(ir)t:ofanJ^ <br />TUJl onpNO <br />Date <br />lermit has been approved by the city/county as stated above). <br />PS09097(8/95)MAR 1.7,1997,