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8- Are the premiws nm% occupied or to be occupied by the applicant eniirek sepzale and exclu.Nic a from any other business <br /> establishment? X Ycs _ No <br /> 9. Stale }N hethcr applicant has or m ill be granted, an On sale Liquor License in conj uuctiou kith this Of] Sale Liquor License and <br /> for the same premises. _D Yes X No J Will be granted <br /> 10. & ale a %hcthcr app licart has or yvill be granted a Sunday On Sale Liquor Liccvse in corg unction a ilh the regular On Sale liquor <br /> 1.iceuse. ; Yes Ai No fJ Will be granted <br /> if. If this application is for a County Board Off Sale License, state the dist ance in miles to the nearest municipality. <br /> 1. Stale a belber applicant or any of the associates in !his applica(ion, have ever had an applieation for a liquor licens=e rg ected by <br /> ar) ntuuicipalih or state authority; if so, give dates and details. _ A10 <br /> 2. I [as t,te applicant or any of the assoc=iates in this application, during the fn•e yeas immediately preceding this application ever <br /> had a license under the Miancsota liquor Control Act revoked for anY violation of such lams or local ordinances; if so, give dales <br /> aid details. A10 <br /> 3. 1 [as applicant, patncrs, officers. or cmplo)'ccs cn•er had any liquor laiv violaionS in Minnesota or cl-se;%here, including State <br /> Liquor Control penalties? Yes 'X No Ifyes, give dates, charges and final outcome. <br /> 4. During the past liceascycar, has a sunmronsbeen issued underthe Liquor Ch it Liabitit) Lain (Thant Slmop) M.S. 340A.802. <br /> Ycs XNo If ycs. allach a copy of the summons, <br /> 'Ibis licensee must have one of the folloning: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br /> arced me <br /> U A. Liquor Liability Inairance (Drern Shop) - $50,000 per person. S100.000 more than ooe puson; S 10,000 property <br /> dcaruction; 550.000 and 5100.000 for loss of means of support. <br /> a <br /> D B. A .virel) bond from a surely company with minimum coverage a5 spec=ified in A. <br /> a <br /> J C. A [Tom the Stale Treasurer that the licensee has deposited i% ilb the -state, trust funds havinginarlet value of <br /> S 100,000 or S 100.000 in cash or securities. <br /> I certify that I have read the above questions and that the answers are true and correct of my own knowledge. <br /> Print name of applicant & title Si tare of Applmcan Date <br /> REPORT BY POLICE%SHERIFF'VDEPARTM9NT <br /> This is to ccnify that e applicau( ei�Fe9 named herein have not been convicted within the pa;a fn eyears for any violation of <br /> la`vs of the State of Miuurso< munic } palordin#nccs relating to intoxicating Liquor except as foUo%�s�? <br /> /�c.. ✓cry ft Lit c'ce > ✓i �Er.�r. i J�4�/J %« �G•. . %� <br /> � /F2C � /�r - (r- i��i ✓�;Y� ^� /Yr (_- �f/c.l _l�tfyL � v <br /> Pokc/SucriO's Dc artm�•ot Titic Siniaturc <br /> PS 9136 -94 <br /> Couuly Arrurnct''s Simaure <br /> I NPORTANT NOTICE <br /> All re!aii liquor licrn secs musi bade a current Federal Special Occupatiooal Stamp, This stamp is issued by the Bureau of Alcohol, <br /> Tubaoco, and Firearms. For information call (6 12)290 -3496. <br />