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L <br />c <br />E <br />N <br />S <br />E <br />E <br />PHONE 612 - 296 -6159 <br />MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIVISION <br />333 SIBLEY • ST. PAUL, MN 55101 <br />CERTIFICATION OF ON SALE LIQUOR LICENSE <br />(TO BE EXECUTED BY CITY CLERK) <br />PS 9011-03 <br />LICENSEE NAME <br />Gus Young's, Inc. <br />TRADE NAME OR DBA <br />Saxon Lanes & Lounee <br />BUSINESS ADDRESS <br />CITY <br />.,-- <br />ZIPCODE <br />61 West Little Canada Road <br />Little Canada <br />55117 <br />LICENSE PERIOD <br />LICENSE NUMBER <br />LICENSE FEE <br />BUSINESS PHONE <br />FROM 7/ /85 TO 6/30/86 <br />38 <br />332 -1741 <br />IF A CORPORATION <br />OFFICER NAME AND TITLE <br />ADDRESS <br />Lloyd Engelsma, President & CFO <br />523 S. <br />ADDRESS <br />8th Street, <br />Mpls., <br />MN 55404 <br />OFFICER NAME AND TITLE <br />Burton F. Dahlberg, Vice President <br />523 S. <br />8th Street, <br />Mpls., <br />MN 55404 <br />OFFICER NAME AND TITLE Secretary <br />/ <br />ADDRESS <br />Bruce W. Engelsma, Vice President, <br />urer <br />523 S. <br />ADDRESS <br />8th Street, <br />Mpls., <br />MN 55404 <br />OFFICER NAME AND TITLE <br />/The Licensee must have one of the following: (The type and amount to be determined by the City Council) <br />(CHECK ONE) <br />8 <br />0 <br />N <br />12. Cash ($3000 to $5000) <br />G OR <br />IX1 <br />OR <br />1. Corporate Surety Bond ($3000 to $5000) <br />A <br />A <br />u <br />T <br />H <br />0 <br />R <br />T <br />St. Paul Companies <br />AMOUNT <br />3. U.S. Gov't Bond ($3000 to $5000) <br />AMOUNT <br />NAME OF BONDING COMPANY AND AMOUNT <br />The Licensee must have one of the following: <br />CHECK ONE <br />X <br />OR <br />11 <br />OR <br />I <br />A. "Certificate of Insurance" — $50,000 per person; $100,000 more than one person; $10,000 property destruction; <br />$50,000 and $100,000 for loss of means of support. ATTACH "CERTIFICATE OF INSURANCE" TO THIS FORM <br />B. A Liquor Libability bond from a surety company with minimum coverages as specified above in A. <br />C. A certificate from the State Treasurer that the Licensee has deposited with the State Trust Funds <br />having a market value of $100,000 or $100,000 in cash or securities. <br />Given Under My Hand and the City Corporate <br />CITY Seal this day of 19 <br />SEAL <br />Clerk and/or Recorder <br />TRANSACTION TYPE [1 NEW <br />L1 RENEWAL [I TRANSFER <br />DATE OF REVOCATION'CANCELLATION <br />REVOKECANCEL <br />[l SUSPENSION <br />DATES SUSPENSION <br />FROM TO <br />CHANGE OF ADDRESS FROM <br />FOR OFFICE USE ONLY <br />CODE <br />EES <br />A <br />C <br />MAILING ADDRESS <br />