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LIQUOR CONTROL DIVISION <br />444 CEDAR ST -SUITE 100 L Tafel, <br />ST. PAUL F!1 55101-2156 ON <br />_ _. _ _. ...N 55101 <br />(612)296-6430 TTY(612)282-6555 <br />RENEWAL OF LIQUOR, WINE, OR CLUB LICENSE <br />No license wit' be approved or released unfit the $20 Retailer ID Card fee 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 0 6/30/95 ID# 6 5 1 6 <br />City/County where license approved Lino Lakes <br />Licensee Name Shirley Kaye ' s Inc. <br />Trade Name Shirley Kaye' s <br />Licensed Location address 6 8 1 0 Lake Dr <br />City, State, Zip Code Lino Lakes, MN 5501 4 <br />Business Phone (6 1 2) 780-4181 <br />LICENSE FEES: Off Sale $ <br />100.00 <br />On Sale $ <br />3,000.00 <br />Sunday $ <br />200.00 <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 />fines. <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 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 />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 />censee Si <br />atur <br />-4 <br />Date <br />(Signature certifies all above information to ----71/,...4..) <br />becorrect and license has been approved by city/county. <br />City Clerk/County Auditor Signature `��/��r✓uo4�J (j/ ,C.CJ�, ,rte Date ���/� <br />L1 <br />(Signature certifies that an on -sale intoxicating liq license has been approved by the city/county as stated above). <br />County Attome _Signature <br />Date <br />County Board issued licenses on <br />ies licensee is eligible for license) <br />Police/Sheriff 'Signature % Date <br />(Signature certifies licensee associes ave not been cited during the past five years for any state/loc liquor law <br />violations (criminal/civil). Report violations on back, then sign here. PS 9093-94 <br />