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10. <br /> <br />I1. <br />12. <br /> <br />14. <br /> <br />Arc thc premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business. <br />establishment? ~rYes ['1 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 />thc same premises. I~Yes Fe~q~ E] 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 Liquor <br />l.icense. Yes ~,r~o !i Will be granted <br />If this application is fora County Board 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 />mnnictpality or state authority; if so, give dates and details. ? ,o <br /> <br />l las thc applicant or any of the associates in this application, during the five years immediately preceding this application ever had a <br />license under thc Miunesota Liquor Control Act revoked for any violation Of such laws or local ordinances; if so, give dates and <br />details ~ o <br /> <br />3. l las applicant, partners, officers, or employees ever had any liquor law violations in Minnesota or elsewhere, including State Liquor <br /> Control penalties'? !J Yes ~v;'l~o If yes, give dates, charges and final outcome. <br /> <br />4. During thc~ast license year, has a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br /> :; Yes /No If yes, attach a copy of the summons. . <br /> <br />This licensee must hr,ye one off the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORXVI.) <br /> <br />('hock OllC <br /> <br /> A. Liqnor 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 /> <br /> It. A surety ~)ond frotn a Surety company with minimum coverage as specified in A. <br /> <br /> : C. A cm~ificate 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 htlve read tim above questions ami that the answers are true anO correct et m~, own lmowletlge. <br />Print name el'applicant & title Signature ~Applicant ~ [Date <br /> Don R. Wetter, CEO, I ~'{~-]~'""5 co I --~ lO_q: <br /> C'nhnrn ' ~ Tnrnr .... <br /> ' REP~I~'- ~Y POLICE\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 Iht Slate of Minnesota or municipal ordinances relating to intoxicating liquor except as follows: <br /> <br />Title <br /> <br />(Munty Attnrncy's Signature <br /> <br />PS 9136-(2003) <br /> <br /> IMPORTANT NOTICE <br /> <br />All retail liquor [ict:nsccs must have a current Federal Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol, Tobacco, <br /> and Firearms. For information ~all (651)726-0220 <br /> <br /> <br />