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Minnesota Department of Public Safety <br />"Wpm <br />ALCOHOL & GAMBLING ENFORCEMENT N I DIVISION <br />• " 444 Cedar St., Suite 133, St. Paul, MN <br />� <br />4., ,� <br />PERMIT <br />DIVISION <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />55101-5133 <br />(651)296-6439 T TY (651) 282-6555 <br />let <br />www.clps.state.inn us/alc�_umh /alcgamb.hnnl <br />` <br />RENEWAL OF CONSUMPTION & DISPLAY <br />Permit Pee 5150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT <br />265 PUBLIC <br />Ho i Yang Inc. <br />My Le i -Ica Cbi.nese Restaurant <br />2900 Rice St 41360 <br />Little Canada, MN 55113 <br />CPolicy Period R%tk $ *a <br />Worker's Comp Ins. Co. i "1'�(� �}S'�j�t�`tvtf) . Policy No.WL72.Z-9it C' j <br />City /County where permit approved: <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 <br />bylaws, membership, partners, home addresses, or telephone numbers. If changes have <br />months, please 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 <br />ownership, corporate officers, <br />occurred during the past 12 <br />of the following will result in fines. <br />/county in the state of <br />below. <br />for any liquor law violation (state <br />then sign below. <br />cited for any civil or criminal <br />renewal, then sign below. <br />period. <br />Date 77 — Zr Ct 1 <br />L <br />2. <br />3. <br />4. <br />5. <br />6. <br />Applicant <br />(Signature <br />City <br />(Signature <br />PS09097 <br />Applicant confirms that it has never had a liquor license rejected by any city/township <br />Minnesota. If ever rejected, please give details 011 the back of this renewal, then sign <br />Applicant confirms that For the past rive years it has not had a liquor license revoked <br />of local). If a revocation has occurred, please give details on the back of this renewal, <br />Applicant confirms that during the past five years it or its employees have not been <br />liquor law violations. If violations have occurred, please give details 011 back of this <br />Applicant confirms that Workers Compensation insurance is in effect for the full license <br />Applicant confirms, no club on -sale intoxicating liquor license is held. <br />Applicant confirms business premises are separate from any other business establishment. <br />Signature L"�c., '_�-.1 : .w t . /v;.�,� <br />certifies all above information to`�)e comet and permit has been approved by city/county.) <br />Clerk /County Auditor Signature Dale <br />certifies that a consumption and display permit has been approved by the city <br />(01/00) <br />. <br />/county as stated above.) <br />I 1 <br />I Amount Received <br />