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8. <br />Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business <br />establishment? Aes ❑ No <br />9. <br />State whether applicant has or will be granted, an On sale Liquor License in conjunction with this Off Sale Liquor License and for <br />the same premises. ❑Yes 'IKNo ❑ Will be granted <br />10. <br />State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale Liquor <br />License. ❑ Yes ANo ❑ Will be granted <br />11. <br />If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. A" d <br />12. <br />13. <br />State Number of Employees <br />If this license is being issued by a County Board, has a public hearing been held as per MN Statute 340A.405 sub2(d)?/y/," <br />14. <br />If this license is being issued by a County Board, is it located in an organized township? If so, attach township appro <br />1. <br />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. ,Z <br />2. <br />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. /'j) <br />3. <br />Has applicant, partners, o Cf icers, or employees ever had any liquor law violations or felony ony convictions in Minnesota or <br />elsewhere, including State Liquor Control penalties? ❑ Yes ,KNo If yes, give dates, charges and final outcome. <br />4. <br />During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br />❑ Yes 'KNo 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 />❑ <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 $100.000 for loss of means of support. <br />or <br />❑ <br />B. A surety bond from a surety company with minimum coverage as specified in A. <br />or <br />❑ <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 />certift <br />that I have read e above questions and tha txkkwers are a an correc o my own knowledge. <br />Pnnt name of app icant & title t aforeifApp <br />Date <br />U <br />�� — <br />REPORT BY ICE\SHERIFF'S DEPARTMENT <br />This is to <br />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-(2009) <br />County Attorney's Signature <br />IMPORTANT NOTICE <br />All retail liquor licensees must register with the Alcohol, Tobacco Tax and Trade Bureau. <br />For information call (513) 684-2979 or 1-800-937-8864 <br />