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Are the premises n~.w occupied <br />establishment7 ~ No <br /> <br />I0. <br />Il. <br /> <br />or to be occupied by the applicant entirely separate and exclusive from any other business <br /> <br />State whether applicant has or will be granted, an On sale Liquor License in conjunction with this Off Sale Liquor License <br />and for the same premises. Yes (~ Will be granted <br />State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Sale <br />Liquor License. Yes (~ W/ti be granted <br />If this application is for a County Board OffSale License, state the distance in miles to the nearest municipality... <br />.Grate Number of Employees '] <br /> <br />State whether applicant or any of the associates in this application, have ever had an application for a liquor license rejected <br />by any municipality or state authority; if so, give dates and details. /d0 <br /> <br />Has the applicant or any o£ thc associates in this application, during the five years immediately preceding this application ever <br />had a license under the Minnesota Liquor Control Act revoked for any violation of such laws or local ordinances; if so, give <br />dates and details. ./Q o <br /> <br />H~ applicant, partners, officers; or__employees ever had any liquor law violations in Mim~esota or elsewhere, including State <br />Liquor Control penalties? Yes ~__~Ifyes, give date-% charges and t-mai outcome. ' ' <br /> <br />During.the~.p_~t license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) lvi. S. 340A.$02. <br /> Yes N~Ifycs, attach a copy of the summons. . ' <br /> <br />fhis licensee'must have one c,f the following: <br /> <br />(ATTACH CERTIFICATE OF INSURANCE TO TH'IS FORM.) <br /> <br />Check <br /> <br />or <br /> B. <br /> <br /> C. <br /> <br />Liquor Liability Insurance (D;-,un Shop).- $50,000 per person, $I00,000 more th~_,'t one person; $!0,000 property <br />destruction; $50,000 and $100.000 for loss of means of support. <br /> <br />A surety boad from a surety corllpany with min.'mum coverage as specified in A. <br /> <br />A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having market value <br />orS100,000 or $100,000 in cash or securities. <br /> <br />I certif that I have he above uestions -,nd that the answers ,'re true and correct own knowled e. <br />Print name of applicant & tide Signature of Appllcant Da~e <br /> <br /> REPORT BY POLICEkSHERIFF'S DEPA17.TMEN? <br />This is to ccrtify that the applicant and the associates named herein have not been convicted within the past five years for any violation <br />of laws of the State of Mirmesota or municipal ordinances relating to intoxicating liquor except as follows: <br /> <br />Police/Sheriffs Department Tide Siffnature <br /> <br />PS 9136-9g <br /> <br />Count~, Attome}/s Signature ....., <br /> I]V~ORTA.NT lWOTICE <br /> All retail liquor Ii~ensce.~ m~st iaavc a'currcnt Federal Special Occupational Stamp. 'i'fiis stamp is issued by the. Bureau of Alcohol, <br /> Tobacc6, and Firearms. For inforrna'tion call (612)290-349& '-:'.'- ':' <br /> <br /> <br />