Minnesota Department of Public Safety ALCOHOL AND GAMBLING ENFORCEMENT DIVISION 444 Cedar St., Suite 222, St. Paul, MN 55101-5133 (651)201-7507 FAX (651)297-5259 TTY(651)282-6555 RENEWAL OF CONSUMPTION & DISPLAY PERMIT and/or OPTIONAL 2 A.M. CLOSING LICENSE Permit Fee $250 (Renewal Date: April 1) IF NAME AND ADDRESS SHOWN ARE NOT CORRECT MAKE CHANGES BELOW Workmens Comp Ins. Co. Policy No. Policy Period ________ City/County where permit approved: Permit Name: Trade Name: Location address: City, State, Zip Code: Business Phone: By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers,bylaws, membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give details on the back of this renewal, then sign below. Applicant's signature on this renewal confirms the following: Failure to report any of the following will result in fines. 1. Applicant confirms that it has never had a liquor license rejected by any city/township/county in the state of Minnesota. Ifever rejected, please give details on the back of this renewal, then sign below. 2. Applicant confirms that for the past five years it has not had a liquor license revoked for any liquor law violation (state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. 3. Applicant confirms that during the past five years it or its employees have not been cited for any civil or criminal liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below. 4. Applicant confirms that Workers Compensation insurance is in effect for the full license period. 5. Applicant confirms, no club on-sale intoxicating liquor license is held. 6. Applicant confirms business premises are separate from any other business establishment. PERMIT HOLDERS APPLYING FOR OPTIONAL 2 A.M. CLOSING LICENSE COMPLETE THE FOLLOWING: 1. Does your liquor license issuing authority allow the sale of alcoholic beverages until 2 AM? Yes No (If Yes, Continue) 3.2% Malt Liquor licensees or Consumption & Display Permit Holders (Set Up licensees) - $200 2 A.M. License Fee 2. Make check payable to: Alcohol & Gambling Enforcement Division (AGED) for the amount indicated above. Include check for 2 AM sales with this application. Applicant Signature Date ______________________________ (Signature certifies all above information to be correct and permit has been approved by city/county. City Clerk/County Auditor Signature Date_______________________ (Signature certifies that a consumption and display permit has been approved by the city/county as stated above). PS09097(05/2009) AMOUNT RECEIVED______________________________ American LegalNet, Inc. www.FormsWorkFlow.com Indicate below changes of corporate officers, partners, home addresses or telephone numbers: Report below details of liquor law violations (civil or criminal) that have occurred within the last five years. (Dates, offenses, fines or other penalties, including Liquor Control Penalties). Report below details involving any license rejections or revocations. City/County Comments: American LegalNet, Inc. www.FormsWorkFlow.com