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Minnesota Department of Public Safety <br />p+�"° ALCOHOL & GAMBLING ENFORCEMENT DIVISION vTNe <br />9 444 Cedar St., Suite 133, St. Paul, MN 55101-5133 <br />(612)296 -6439 TTY(612) 282 -6555 A . t -c-" <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $150 (Renewal Date: April 1) <br />MAKE CHECKS PAYABLE TO: ALCOHOL & GAMBLING ENFORCEMENT DIVISION <br />269 PUBLIC <br />Hoi Yang Inc. <br />My Le Hoa Chinese Restaurant <br />2900 Rice St #360 <br />Little Canada, 55113 <br />IF NAME AND ADDRESS <br />SHOWN ARE NOT CORRECT, <br />MAKE CHANGES BELOW <br />)MN <br />Worker's Comp Ins. Co. �n <br />2/q8— R'OJLS0A2 Policy No 0�iQ— �PolicPeriodL�/2/g8— %12 /cif <br />RI <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,bylaws, <br />membership, partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please <br />give details on the back of this renewal, then sign below. <br />Applicant's signature on this renewal confirms the following: Failure to report any of the following will result in <br />fines. <br />1. Applicant confirms that it has never had a liquor license rejected by any city /township /county in the state of Minnesota. <br />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 />or 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 liquor <br />law violations. If violations have occurred, please give details on hack 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 bus' ess premises are separate from any other business establishment. / el <br />Applicant Signature ) 7� Date - (7 - ` <br />(Signature certifies all above information to e cor�ct 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 (10/97) <br />Amount Received <br />Page 113 <br />