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Mounds View Temporary Liquor License Application Page 2 municipality; and I hereby certify that I have read this application in its entirety and that the answers provided are true. x Signature of Person Responsible: da#e: ��` _ 3 TENNESSEN WARNING 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 rehabilitation and present fitness to perform the duties of the occupation (Minnesota Srotute 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/organizations named on this application. My signature constitutes agreement of the Tennessen Warning and application. x Signoi of Responsible Person Insurance Requirements: A certificate that there is in effect an insurance policy issued by an insurer required to be licensed by Minnesota Statutes, Section 60A.07, subdivision 4 or by an insurer recognized as an eligible surplus line carrier pursuant to Minnesota Statutes, Section 60A.206 or pool providing coverage of at least: (1) Fifty thousand dollars ($50,000.00) for bodily injury to any one person in any one occurrence and subject to the limit of one person; (2) One hundred thousand dollars ($100,000.00) for bodily injury to two or more persons in any one occurrence; (3) Ten thousand dollars ($10,000.00) for injury to or destruction of property of others in any one occurrence; (4) Fifty thousand dollars ($50,000.00) for loss of means of support of any one person in any one occurrence and, subject to the limit for one person; and (5) One hundred thousand dollars ($100,000.00) for loss of means of support of two or more persons in any one occurrence. Required to be Submitted: Notes - Temporary Liquor License Application Form ® Criminal Background Release Form 0 Certificate of Insurance © Fee $120 (includes background check) 0 Copy (front and back) of Driver's License