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Minnesota Dqjartment of Public Safety <br />UQUOR CONTROL DIVISION <br />444 Cedar SU Suite 100 L. St. Paul. MN 55101-2156 <br />(612)296-6439 TTY(612)282-6555 <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fe« $150 (Reiiew*l D*te: April I) <br />5598 PUBLIC <br />Navarre Lanes Inc. <br />Navarre Lanes <br />Box 51 <br />Navarre, HN 55392 <br />IF NAME ADDRESS * ♦ ' <br />SHOWN ARB NOT CORRECT, j <br />MAKE CHANGES BELOW <br />Workmens Comp Ins. Co.Policy No.Policy Period <br />City/County where permit approved; <br />Permit Name; <br />Trade Name: <br />Location address: <br />City, State, Zip Code; <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 />Applkant's signature on this renewal confirms the following: Failure to report anv of the following will result In <br />QoSSi <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, plea.se 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 (slate <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 back of this renewal, then sign below. <br />4. Applicant confirtns tliat Workers Compensation itisurniicc 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 busine^srrcmi»i arp>separate from any other business establishment. <br />Applicant Signature Date <br />(Signature certifies all a^vc infojHaation to be correct and permit has been approved by city/county. ^ ^ <br />City CIcrk/Countv 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)Aniotuil itiecelved • <br />1 • V4*'. » « 1 ••. ...-•/to