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Minnesota Department of Public Safety <br />s �r • �\ LIQUOR CONTROL DIVISION rs �_ <br />,- °, 444 Cedar Si., Suite 100 L, St. Paul, MN 55101 -2156 <br />/ (612)296 -6439 TTY(612)282 -6555 Ez <br />MIL <br />RENEWAL OF CONSUMPTION & DISPLAY PERMIT <br />Permit Fee $150 (Renewal Date: April I) <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 />CO: cy`x-tbcrral km At(15vZ, <br />Workrnens Comp Ins. Co. V\LLRfL Ol.C.ivi -S%wl r' Policy No. LLXF -CC q.2 Z 2- ccPolicy Period <br />City /County where permit approved: (,C f a, <br />Permit Name: Hoi Yang Inc. <br />Trade Name: My Le Hoa Chinese Restaurant <br />Location address: 2900 Rice Street #360 <br />City, State, Zip Code: Little Canada , MN 55113 <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 011 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 hack 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 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 l.�(�( Civ A t Date ,--,?/c2 c2 (I/ �% <br />/ / 4 <br />(Signature certifies all above information to cor ct and permit has been approved by city /county. <br />City Clerklf�,Signature Date <br />1 (Signature certifies that a consumption and display permit has been approved by the city /county as stated above). <br />s,,,. <br />MAR 10jf3 'p <br />; <br />PU9IlE .',A # <br />PS09097(8/95) A 4' <br />,P <br />73 <br />Amount Received /So et <br />Page .6 <br />