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4. Has the applicant or any of the associates in this application been convicted during the past five years of any violation <br />of federal, state or local liquor laws in this state or any other state? ❑ Yes &No If yes, give date and details. <br />5. Does any person other than the applicants, have any right, title or interest <br />in the licensed premises? ❑ Yes j'No If yes, give names and details. <br />in the furniture, fixtures or equipment <br />6. Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? <br />❑ Yes 2'No If yes, give name and address of the establishment. <br />I CERTIFY THAT I HAVE READ THE ABOVE <br />TO THE BEST OF MY OWN KNOWLEDGE. <br />QUESTIONS AND THAT THE ANSWERS ARE TRUE AND CORRECT <br />U-j-� 4c...r X. y � 6/a /9.t <br />Sig6atJr�of Applicant / ate <br />The Licensee must have one of the following: <br />CHECK ONE <br />X A. Liquor Liability Insurance (Dram Shop) — S50,000 per person; $100,000 more than one person; $10,000 <br />property destruction; $50,000 and $100,000 for loss of means of support. ATTACH "CERTIFICATE OF <br />INSURANCE" TO THIS FORM. <br />OR <br />1 1 B. A Surety bond from a surety company with minimum coverages as specified above in A. <br />OR <br />C. A certificate from the State Treasurer that the Licensee has deposited with the State, Trust Funds having <br />a market value of $100,000 or $100,000 in cash or securities. <br />IF LICENSE IS ISSUED BY THE COUNTY BOARD, REPORT OF COUNTY ATTORNEY <br />I certify that to the best of my knowledge the applicants named above are eligible to be licensed. ❑ Yes ❑ No <br />If no, state reason. <br />Signature County Attorney <br />County <br />Date <br />REPORT BY POLICE <br />This is to certify that the applicant, and the associates, <br />five years for any violation of Laws of the State of <br />Ordinances relating to Intoxicating Liquor, except as <br />OR SHERIFF'S DEPARTMENT <br />named herein have not been convicted within the past <br />Minnesota, Municipal or County. <br />follows <br />Police, Sheriff Department Name <br />Title <br />Signature <br />IMPORTANT NOTICE <br />ALL RETAIL LIQUOR LICENSEES MUST HAVE A CURRENT FEDERAL SPECIAL OCCUPATIONAL <br />STAMP. THIS STAMP IS ISSUED BY THE BUREAU OF ALCOHOL, TOBACCO AND FIREARMS. FOR <br />INFORMATION, CALL 612 - 290 -3496. <br />Page 2 <br />