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8. Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business establishment? (Yes 0 No 9. State whether applicant has or will be granted, an On sale Liquor License in conjunction with this Off Sale Liquor License and for the same premises. 13Yes kNo ❑ Will be granted 10. State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor License. ❑ Yes ko Will be granted 11. If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. 12. State Number of Employees 13. If this license is being issued by a County Board, has a public hearing been held as per MN Statute 340A.405 sub2(d)? 14. If this license is being issued by a County Board, is it located in an organized township? If so, attach township approval. State whether applicant or any of the associates in this application, have ever had an application for a liquor license rejected by any municipality or state authority; if so, give dates and details. `A/(.7 Has the applicant or any of the associates in this application, during the five years immediately preceding this application ever had a license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so, give dates and details. /✓ (� Has applicant, partners, officers, or employees ever had any liquor law violations or felony convictions in Minnesota or elsewhere, including State Liquor Control penalties? ❑ Yes 4-No If yes, give dates, charges and final outcome. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. ❑ Yes .moo If yes, attach a copy of the summons. This licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) Check one A. Liquor Liability Insurance (Dram Shop) - $50,000 per person, $100,000 more than one person; $10,000 property destruction; $50,000 and $100.000 for loss of means of support. or o B. A surety bond from a surety company with minimum coverage as specified in A. or ❑ C. A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having market value of $100,000 or $100,000 in cash or securities. 1 cerkiy that 1 have read the above questions and that the answers are true and correct of my own knowledge. Print name of applicant & title Signature of Applicant Date ;r. REPORT BY POLICE \SHERIFF'S D RTMENT f( G7 ac ll_ This is to certify that the applicant and the associates named herein have not been convicted within the past five years for any violation of laws of the State of Minnesota or municipal ordinances relating to intoxicating liquor except as follows: Police /Sheriffs Department Title Signature PS 9136 - (2006) County Attorney's Signature IMPORTANT NOTICE All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, and Firearms. For information call (651)726 -0220