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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 <br />establishment?'es ONo <br />9. State whether applicant has or vill be armed, an On sale Liquor License in conjunction with this Off Sale Liquor License and for <br />the same premises. ❑Yes i No <br />10. State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor <br />License. 0 Yes KNo 0 Will be granted <br />11, If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. <br />12. State Number of Employees <br />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)? <br />14. If this license is being issued by a County Board, is it located in an organized township? If so, attach township approval. <br />1. State whether applicant or any of the associates in this application, have ever had an application for a liquor license rejected by any <br />municipality or state authority; if so, give dates and details. 7? p n(, <br />2. Has the applicant or any of the associates in this application, during the five years immediately preceding this application ever had a <br />license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so, give dates and <br />details. 22 a/7-� <br />3. %las applicant, partners, officers, or employees ever had any liquor law violations or felony convictions in Minnesota or <br />elsewhere, including State Liquor Control penalties? 0 Yes (1No If yes, give dates, charges and final outcome. <br />4. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br />0 Yes .»'N.o If yes, attach a copy of the summons. <br />This licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />Check one <br />A. Liquor Liability Insurance (Dram Shop) - $50,000 per person, $100,000 more than one person; $10,000 property <br />destruction; $50,000 and 5100.000 for loss of means of support. <br />er <br />o 13. A surety bond from a surety company with minimum coverage as specified in A. <br />or <br />❑ C. A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having market value of <br />$100,000 or $100,000 in cash or securities. <br />1 certify that 1 have read the above questions and that the answers are true and correct 'Amy own knowledge. <br />hint name of' applicant & title Signature of ApplicantDate <br />424yL LE -ES: VA} ti 6- iri4ti ,l,� C)2(4' ,4 13 -it-Lc <br />REPORT BY POLICE\ ERIFF'S DEPA TMENT <br />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 <br />laws of the State of Minnesota or municipal ordinances relating to intoxicating liquor except as follows: <br />Police/Sheriffs Department Title Signature <br />PS 9136-(2006) <br />County Attorney's Signature <br />IMPORTANT NOTICE <br />All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, <br />and Firearms. For information call (651)726-0220 <br />