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Minnesota Department of Public Safety <br />ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />444 Cedar St., Suite 133, St. Paul, MN 55101 -5133 <br />(651) 296 -6439 TTY (651) 282 -6555 <br />www.dps. state .mn.us /alcgamb /alcgamb.html <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 <br />Hoi Yang Inc. <br />My Le Hoa Chinese Restaurant <br />2900 Rice St #360 <br />Little Canada, MN 55113 <br />PUBLIC <br />Worker's Comp Ins. Co. h ra c <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />Policy No.It/C. -22-4 firidOPolicy Period 'Z�' 200 i) 'S <br />City /County where permit approved: <br />'g a M <br />`7 <br />Permit Name: <br />Trade Name: <br />Location address: .40/00 ;ce. _S fi <br />City, State, ZIP Code: L t 1,..(_.(e_ C C1/4. y 1 0,. «e <br />M N <br />-5-} -/ / <br />3 <br />Business Phone: (6,5 0 _ T ?zit _ 5353 <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 follow' n : Failure to re ort an of the foliowin 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, no club on -sale intoxicating liquor license is held. <br />6. Applicant confirms business premises are separate from any other business establishment. <br />Applicant Signature z <br />(Signature certifies all above informat <br />0 <br />Date 0/'" 3 ( o / • <br />e correct and permit has been approved by city /county.) <br />City Clerk/County Auditor Signature Date <br />(Signature certifies that a consumption and display permit has been approved by the city /county as stated above.) <br />PS09097 (01 /00) <br />Page 18 <br />Amount Received <br />