Laserfiche WebLink
Minnesota Department of Public Safety yEST _ <br />;ovw o`.. ' <br />ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />9� =1 -14 Cedar St., Suite 133. Si . Paul. MN 55101 -6133 „,,a, es <br />L""i s 296 TTY (65l) 28'2 . <br />(661) -6439 -6006 <br />3t- <br />www.dps.state.mn.us/alcgamb/alcgamb.html <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee 3150 (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 Resta:.t ant <br />2900 Rice St #360 <br />Little Canada, MN 55113 <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />NIAKE CHANGES BELOW <br />Comp % C7 )('. Wu” - Cy- 0ci`ii-sL cz. <br />Worker's Com Ins. Co. Policy No. Policy Period S S k 2 - S 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 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 />Applicant's sinnature on this renewal confirms the following: Failure to report any of the following 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 had 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, n0 club on -sale intoxicating liquor license is held. <br />6. Applicant confirms business premises are separate from any other business establishment. <br />Applicant Signature .-1...:-/-6r �� •��s�,.1ti,ri. ✓L_ Date -7— �7— G' <br />(Signature certifies all above information to be correct and permit has been approved by city /county.) <br />City Clerk /County Auditor Signature Dire <br />(Signature certifies that a consumption and display permit has been approved by the city /county as stated above.) <br />PS09097 t01 /OUM 1 Amount Received <br />