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LIQUOR CONTROL DIVISION <br />444 CEDAR ST -SU I TE 100 L iafety <br />ST. PAUL f*! 55101-2156 ON <br />_N 5101 <br />(612)296-6430 TTY(612)282-6555 <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />• No licen%e will be approved or released untli the S20 Retailer lila Cud tee is received by MN liquor Control <br />Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City <br />Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new <br />license period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any license <br />cancellation. <br />License Code CM B S License Period Ending 06/30/96 ID # 6 516 <br />City/County where license approved L i n o Lakes <br />Licensee Name Shirley Kaye ' s Inc . <br />Trade Name Shirley Kaye ' s <br />Licensed Location address 6 810 Lake Dr <br />City, State, Zip Code L i no Lakes , MN 55 014 <br />Business Phone( 612) 780-4181 <br />LJCENSE FEES: Off Sale $ 10 0. 0 0 On Sale $ 3, 0 0 0. 0 0 Sunday $ 2 0 0. 0 0 <br />By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, <br />partners, home addresses, or telephone numbers. If changes have occurred during the past 12 months, please give details <br />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 />mes. <br />1. Licensee 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. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation <br />(state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below. <br />3. Licensee confirms that during die 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. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability Law <br />(Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below. <br />5. Licensee confirms that Workers Compensation insurance is in effect for the full license period. <br />licensee has attached a liquor liability insurance certificate that corresponds with the license period in city/county <br />where license is issued. $100,000 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor <br />liability. <br />Licensee Signature /ALL' <br />A/116-6-7 a ( Date ,S' - 30 - 9!0 <br />(Signature certifies all above information to be correct and license has been approved by city/county. <br />67:--e16)- Date c 3 / <br />City Clerk/County Auditor Signature <br />(Signature certifies that an on -sale intoxicating lic'ior license has been approved by the city/county as stated above). <br />County Attorney Signature Date <br />County Board issued licenses only (Signature certifies licensee is eligible for license) <br />Police/Sheriff Signature Date <br />(Signature certifies licensee or associates have not been cited during the past five years for any state/local liquor law <br />violations (criminal/civil). Report violations on back, then sign here. PS 9093-94 <br />