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8. Are the premises no occupied or to be occupied by the applicant entirely separate and exclusive from. any other business <br />establishinent? E'Yes D No <br />9. State whether applicant has or will be granted, an On sale Liquor License in conjunefion with this Off Sale Liquor License and for <br />the carne premises. OYe,s P14"o 0 Will be granted O <br />10. State whether apphea 't has i <br />s orwill be granted a Sunday On Sale Liquor License n conjunction with the regular n Sale Liquor <br />License. Y I es WXo 11 Will be anted 119 <br />If this application is for a Counr municipality. <br />Off Sale License, state, the distance in miles to the nearest municipali <br />� -7 i M 0 t C <br />1.2', State Number of Employees a P"y _ _tV ) <br />131.1 If this. license is being issued by a County hoard has a public hearing been held as per MN Statute 340A.405 subs d)? 1/4 <br />14. If this license is being issued by a County Board, is it located in an or township? If so, attach township approval. <br />1. State whether applicant or any olf'the associates in this application, have evier, had. an appl ication for a liquor license rejected lay any <br />municipality or state authority;, if so, give dates and. details. V <br />12. Has the applicant or any of the associates in this application, during the fiva 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 mid <br />details. 1/ 0 <br />in Minnesota or <br />3. Has app scant, partners, officers, or employees ever had any liqu violations lony convictions <br />elsewhere, including State Liquor Control penalties? D Yes E�?Owif yes, give dates, charges and final outcome. <br />4. During the Ipst license year, has a, summons been issued under the Liquor Civil, Liability Law (Dram Shop) M.S. 340A. 802. <br />Q Yes 94o If yes, attach, a copy, of the stimmons. <br />This, licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />C��Ione A. Liquor Liability Insurance (Dram Shop) - $50,000 per person, $100,10,00, more than one person; $10,000 property <br />destruction; $50,01010 and, $100.000 for loss of means of support. <br />or <br />U S. A surety blond from a surety company with mem'imurn coverage as specified in A. <br />or <br />O C1. A certificate from the State Trcasurer that the licensee has deposited with the state, trust funds having market value of <br />$100,,000 or $100,000 in cash or securities. _Mn owe Vie.. Tavie ricad THE z y <br />T 7471117 75 at I gove owes an h__e answers are true an of M <br />lican <br />3rint name of apipficant tit lie Kgnature of 't Date <br />E'duJaVC1 EI J(Vtz_� Velseloiretak I ­ -7 J-7 101 <br />- - � / vrear 2 <br />I 13TWOns <br />phi's is to certify that the applicant and the associates named herein have not been convicted with' the. past five years for any violation. of <br />laws of the State of Minnesota or, municipal ordinances relating to intoxicating liquor �except as baylows: <br />Police/Sheriff s Department Title <br />0=11 <br />PS 9136-(2006) <br />County Attomey's Signature <br />A,lll retail liquor licensees must have a current Federal Special Occupational Stamp. 'This stamp is issued by the Bureau of Alcohol, Tobacco, <br />and Firearms. or infonnatiort call (65'1)726-0220 <br />