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Mounds View Temporary Liquor icense Applicatiol Page 2 i icipality; and I hereby ce (fy that I have read this application in its entirety and that the answers ded are true. nature of Person Respol 1;l sible: �' �Date:WARNING rGovemment on this form will be used to approvyour license. some reque ted data Is private. Private data is available to you and the Ci y or State need this Information to perform t elr duties, but is not availa le to the public. eing asked to answer questions an provide information purs ant to the application process that is required by Minnesota State Statute ity of Mounds View. The informati n you provide isgovernme t data in accordance with Chapter 13 of State law known asth "Minnesota ent Data Practices Act". You are n t required by law or ordina ce to answer questions or provide the information requested Arefusalto uestions or provide information be ng; requested will prevent he City of Mounds View from processing the application for hich you are applying The information you provide may be classifi this information can be obtained by person d as "public", "private" or w� o are deemed eligible `confidential" pursuant to the "Government Data Practices A pursuant to the "act". This access Include ". Access to application, anyone they give their informed o i sent to consistent with can the subject(s) Ainnesota State law, or by court order. of the license I understand that a criminal conviction will n t bar me from obtaining a I cense unless the conviction is directly related to the the license is sought and there is no showing ofsufficlent rehabilitation occupation nd present fitness to perform the duties of the occupation (M for which nnesotp Statute 365.03). 1 understand that falsificatic n of the application; includi ig failure to reveal a criminal conviction, constitutes grounds i or denial of the license. The information I have provided on this appli tion is truthful. I authoriz� the City of Mounds View to investigate the information and contact persons/organizations named on this applica ion. My signature constitul es agreern the, a nessen Warning and application. Signature of Res n lonsi�IgPet Insurance Requirements: A certificate licensed by Minnesota Statutes, Se i that there is in effect tion 60A.07, n insurance policy issued by an insurer required to be line carrier pursuant to Minnesota Statutes, subdivision Section 60A.20 4 or by an insurer recognized as an eligible si or pool providing coverage of at least: (1) Fifty the irplus usand dollars ($50,000.00) for bodily injury t One hundred thousand dollars ($100,6d0.00) a 6ny one person in arty for bodily injur one occurrence and subject to the limit of one person,- t to two or more in (2) thousand dollars ($10,000.00) for i 'uiy to or destruction persons any one occurrence; (3. of property of others in any one occurrence; (4) F Ten fty thousand dollars ($50;000.00) for JOE s 6f means of support of any one person in any one occurrence and, subject to the limit for one person; and (5) -n I e hundred thousand dollars ($100,000.00) for loss of means of support of two or more persons in any one occurren e.1 Required to be Submitted: motes; ❑ Temporary Liquor License App] cation Form ❑ Criminal Background Release F orhi ❑ Certificate of Insurance F]Fee $115 ($100 plus $15 back g obfid check) ❑ Copy (front and back) of Driver' 10Tense �I