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Docu5ign Envelope ID; 00550633-1436-125D-A603-68CEE44A37A2 Mounds View Liquor License Application Page 2 Is the maximum occupancy for the ❑ You have or will apply for a Tobacco license for the premises to be licensed [ You have or will apply for an Amusement Device license for the premises to be licensed F-1 You have or will apply for a Restaurant license for the premises to be licensed 0 Proof of insurance is attached ❑ This is a new or transfer license and the required floor plain Is attached Have you ever had a license revoked? 0 No ❑ Yes If yes, please attach explanation. I and my associates in this application will strictly comply with all the laws of the State of Minnesota governing taxation and the sale of alcohol; rules and regulations promulgated by the Alcohol and Gambling Enforcement division the Department of Public Safety; and all ordinances of the municipality; and I hereby certify that I have read this application in its entlrety and that the answers provided are true.„��,� _ Signature of Applicant: I "w Cbwor TENNESSEN WARNING Date: Va-(-f ) a The data on this form will be used to approve your license. Some requested data is private. Private data is available to you and the City or State staff who need this information to perform their duties, but is not available to the public. You are being asked to answer questions and provide information pursuant to the application process that is required by Minnesota State Statute and the City of Mounds View. The Information you provide Is government data in accordance with Chapter 13 of State law known as the "Minnesota Government Data Practices Act". You are not required by law or ordinance to answer questions or provide the information requested. A refusal to answer questions or provide Information being requested will prevent the City of Mounds View from processing the application for which you are applying. The information you provide may be classified as "public", "private" or "confidential" pursuant to the "Government data Practices Act". Access to this information can be obtained by persons who are deemed eligible pursuant to the "act". This access can include the subject(s) of the license application, anyone they give their informed consent to consistent with Minnesota State law, or by court order. I understand that a criminal conviction will not bar me from obtaining a license unless the conviction is directly related to the occupation for which the license is sought and there is no showing of sufficient rehabllitatlon and present fitness to perform the duties of the occupation (Minnesota Statute 365.03). 1 understand that falsification of the application, including failure to reveal a criminal conviction, constitutes grounds for denial of the license. The Information I have provided on this application is truthful. I authorize the City of Mounds View to investigate the information and contact persons/organlzations named on this application. My signature constitutes agreement of the Tennessen Warning and application. OocuSlAned by! x w [,etn In er Applicant's signature Tax Clearance Worker's Comp Law ■ Criminal Background Release Form State Buyer's Card (Liquor Stores and Bars Off -sale Liquor Only -- New Only, State Sends Renewals Directly) ■ Applicable State (A&GE) Liquor License Application Police Chief: ❑ Approved ❑ Denied Other (New or Renewal) ❑ Back Ground Check ❑ Public Hearing Conducted (including mailing & publication) ❑ Fire inspection Completed