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Application for County or City On -Sale Wine License Page 2 of 3 <br />CI Yes K1 No +t. funs tinpliaud, partner:, of1ieciv or employees ever'hacl any liquor law violations in Minnesota or elsewhere, <br />If so, Five naives, dales, violations and final nnleeinc. <br />0 Ye ).No 5. foes any pctson other than the applicants, have any right, title interest in the furniture, fixtures or equipment <br />in the lie:used.priii tit Ifp'as, give tunics and tlet:als tr i s C_,° A CL 6i/ re-it <br />J CI <br />CI Yes Ni} 6. Have the applicants tiny intemsts, throatily or inditcetly, in any other liquor establishments in 1•liun 4)1a"7 if yes, <br />give name and address of the establishment. <br />I CERTIFY THAT 11 HAVE READ "in <br />I3EsTOFFIVfY OWN P NOW1dzIX 1 . <br />OV1% QuitsTi T O UE NS 1) `I 64,4 £THIS ANSwt Rs ARE TRUE .AND ))121 j ,C'r T <br />l'. A: y <br />'no linen: <br />Circa. one <br />A. <br />tunst. have oit,4, of the following: <br />Sipaim:c of Aticait <br />f.icptor. [. €ability Insurance (Dram Shop).S5i,i,000 per person; 5''00,000 more than one person; $10,000 property destruction; <br />S50, 0Ct0 and $ 1OO,000 for loss of means ofsupport. AItk CFI "CERTIFICATE OFINSURANCE "'['C tiusFORM. <br />A. Surely bond from a surety company with minimum coverage as specified above in A. <br />.J C. A certificate from the State "'Waster Utat the Licensee has deposited with the Stale, 'I't1Lt Funds having a market value of <br />S l tk`. 000 or $100;070 in cash or securities. <br />IFLTCENSE IS ISSUED BY THE COUNTY 1IOABD, REPORT OF COUNTY ATTORNEY <br />0 Yes 0 No I cerlitY that W the best ofury tcaowiedge the applicants narncd above are eligible to be licensed. <br />if no, state reason. <br />Signature County Attorney <br />County Date <br />REPORT BY PMICE OR SHERIFF'S DEPARTMENT <br />This is to certify drat the applicant and tic associates, named therein have not boon convicted within the past five years fix mty violation of <br />Lawn of the State of Minnesota, 'Municipal. or County Ordinations relating to Intoxicating liquor, e%copt as hallows <br />Signature <br />Title Department Name <br />IMPORTANT NOTICK <br />ALL RETAIL LIQUOR LICENSEES MUST HAVE A CURRENT FEDERAL, SPECIAL OCCUPATIONAL <br />STA,YIP. MIS STAMP IS ISSUED BY THE BUREAU OF ALCOHOL, TOBACCO AND FIREARMS. <br />FOR INFORMATION, CALL (612)290 -3495 <br />Last Modified:Monday, August 20, 2001. <br />URL http: / /www.dps. state. mn. us /alcgamb /alcenf /forms /consw.html <br />http: / /www.dps.state.mn.us /alcgamb /alcenf /forms /consw.lrtml 05/09/2003 <br />