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Minnesota Department of Public Safety <br />ALCOHOL & (AMBLING ENFORCEMENT DIVISION <br />' 444 Cedar Si Suite 133, Si Paul, MN 55101 <br />-5133 <br />kr (651) 296 -6439 TTY (651)282 6555E • <br />^�yc <br />�4� psi www dps state. mn .us /alcgamb /alcgamb.html �y <br />xmm, y ix,x tV <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $ 150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />289 PUBLIC <br />Hoi Yang Inc. <br />My Le Hoa Chinese Restaurant <br />2900 Rice St #360 <br />Little Canada, MN 5/511399 <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />7 <br />Worker's Comp ins. Co. b �(ill,r L L�- Policy NoMA: _ _ _ „�j' ohcy Period �')�' / • �r�(/ <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 ownership, corporate officers, <br />bylaws, membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 <br />months, please give details on the back of this renewal, then sign below. <br />A licant's si nature on this renewal confirms the foliowin : Failure to re tort an of the followin ' will result in fines. <br />1. Applicant confirms that it has never had a liquor license rejected by any city /township /county in the state of <br />Minnesota. 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 hacl a liquor license revoked for any liquor law violation (state <br />of 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 <br />Liquor 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 club on -sale intoxicating liquor license is held. <br />6. Applicant confirms business premises are separate from any other business establishment. 7 �y <br />Applicant Signature <' ,%..- DatefJ 7 & _a_! <br />,) <br />(Signature certifies all above information &6 be (., Erect and permit has been approved by city /county.) <br />City Clerk /County Auditor Signature Date <br />(Signature certifies that a consumption u and display permit has been approved by the city /county as stated above.) <br />PS09097 (01 /0) <br />Amount Received <br />