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9. <br /> <br />Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive fi.om any other business <br />establishment'? t~Yes '~ No <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, t.lYes ~No t2 Will be granted <br />State whether applicant has or will be granted a Sunday On Sale Liquor License in conjunction with the regular On Stile Liquor <br />License. ~1 Yes '~ No U Will be granted <br />If this application is for a County B_oard Off Sale License, state the distance in miles to the nearest municipality. _ <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)? <br />If this license is being issued by a County Board, is it located in an organized township? If so, attach township approval. <br /> <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. ,&/g~ <br /> <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. /F/j <br /> <br />Has applicant, partners, officers, or employees ever had any liquor law violations in Minnesota or elsewhere, including State Liquor <br />Control penalties'? t~ Yes ~34qo If yes, give dates, charges and final outcome. <br /> <br />4. During the past license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br /> t~ Yes ~ No If yes, attach acopy of the summons. <br /> <br /> This licensee must have one of the following: g. " (~TACIf CERTIFICATE OF INSURANCE TO THIS FORM.) <br /> Check one :¢ ~ <br />~ A. Liquor Liability Insurance (Dram Shop).- $50,900 p'~r person, $100,000 more than one person; $10,000 property <br /> destruction; $50,000 and $100.000 for l'6ss of metm~of support. <br />or ~'~ <br /> ~1 B. A surety bond from a surety company w. ith minimun~ coverage as specified in A. <br /> <br /> t~ 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 /> I certii~' that I have reaa the aoove quesnons anti that the answers are true ana correct ot m[ own ~nowtea~e. <br /> Print name of applicant & title , Signature of Applicant Date / , <br /> REPORT BY POLI(~E~SHERIFF'S DEPARTMENT <br /> <br />This is to 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 /> <br />Title <br /> <br />County Attorney's Signature <br /> <br />PS 9136-(2003) <br /> <br /> IMPORTANT NOTICE <br /> <br />All retail liquor licensees must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, <br /> and Firearms. For information call (651)726-0220 <br /> <br /> <br />