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Minnesota Department of Public Safety <br />t ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />Y 1' 444 Cedar St., Suite 133, St. Paul, MN 55101 -5133 <br />(651) 296 -6439 TTY (651) 282 -6555 <br />PERMIT <br />`, <br />. <br />.. -.- <br />DIVISION <br />"gar- www.dps. state .mn.us /alcgatnb /alcgamb.html <br />RENEWAL OF CONSUMPTION & DISPLAY <br />Permit Fee $150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT <br />289 PUBLIC <br />Hoi Yang Inc. <br />My Le Hoa Chinese Restaurant <br />2900 Rice St #360 <br />Little Canada, MN 55113 <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT,.] <br />MAKE CHANGES BELOW <br />p <br />Policy Period Dp-OSI-f 9 -to D?-o -2.»o <br />Worker's Comp Ins. Co. ( ,J &ttAS4(,L Policy No.0. 0- 00- /412//9 <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 followin : Failure to re ort an of the followin • will result in fines. <br />1. <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 /county in the state of <br />Minnesota. If ever rejected, please give details on the back of this renewal, then sign below. <br />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 />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 />Applicant confirms that Workers Compensation insurance is in effect for the full license period. <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 -ix, 71.915-144.---y, ,`. Date 3 — 41— <br />eZ <br />certifies all above information to 6e correct and permit has been approved by city /county.) <br />Clerk/County Auditor Signature Date <br />certifies that a consumption and display permit has been approved by the city <br />(01/00) <br />Page 117 <br />/county as stated above.) <br />Amount Received <br />