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Mounds View Temporary Liquor License Application Page 2 • municipality; and I hereby certify that l have read this application in its entirety and that the answers provided are true. Dater' zc> /r X Signature of Person Responsible: f� ' The data on this form will be used to approve your license. staff who need this information to perform their duties, You are being asked to answer questions and provide and the City of Mounds View. The information you provide Government Data Practices Act". You are not required answer questions or provide information being requested 0 applying. The information you provide may be classified as "public", this information can be obtained by persons who are application, anyone they give their informed consent I understand that a criminal conviction will not bar me the license is sought and there is no showing of sufficient Statute 365,03). I understand that falsification of the the license. The information I have provided on this application is persons/organizations named on this application. My TENNESSEN Some requested but is not available information pursuant is government by law or ordinance will prevent the "private" or "confidential" deemed eligible pursuant to consistent with Minnesota from obtaining a license rehabilitation and application, including truthful. I authorize signature constitutes X WARNING • data is private. Private data is available to the public. to the application process that is required data in accordance with Chapter 13 of State to answer questions or provide the information City of Mounds View from processing pursuant to the "Government to the "act". This access can include State law, or by court order. unless the conviction is directly related present fitness to perform the duties failure to reveal a criminal conviction, the City of Mounds View to investigate agreement of the Te esse arning to you and the City or State by Minnesota State Statute law known as the "Minnesota requested. A refusal to the application for which you are Data Practices Act". Access to the subject(s) of the license to the occupation for which of the occupation (Minnesota constitutes grounds for denial of the information and contact d application. Applicant's signa re Insurance Requirements: A certificate that there is in effect an insurance policy issued by an insurer required to be 60A.07, subdivision 4 or by an insurer recognized as an eligible surplus Section 60A.206 or pool providing coverage of at least: (1) Fifty thousand one person in any one occurrence and subject to the limit of one person; (2) for bodily injury to two or more persons in any one occurrence; (3) Ten or destruction of property of others in any one occurrence; (4) Fifty of support of any one person in any one occurrence and, subject thousand dollars ($100,000.00) for loss of means of support of two licensed by Minnesota Statutes, Section line carrier pursuant to Minnesota Statutes, dollars ($50,000.00) for bodily injury to any One hundred thousand dollars ($100,000.00) thousand dollars ($10,000.00) for injury to thousand dollars ($50,000.00) for loss of means to the limit for one person; and (5) One hundred or more persons in any one occurrence. Required to be Submitted: Form Notes: C 4C 3 0 $ 7 ,y �j/�j etXt V'st,Q .- T�L! 4404 be/A3/4W)q 4,-3 7 /V a Temporary Liquor License Application 1 Criminal Background Release Form / IM Certificate of Insuranc __.. _ L1 Fee $115 ($100 plu $1 background c�ck) ❑ Copy (front and back f-Dfivr°s Lic