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8. <br />9. <br />10. <br />11. <br />12. <br />13. <br />14. <br />Are the premises now occupied or to be occupied by the applicant entirely separate and exclusive from any other business <br />establishment? �es ❑ 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. ❑Yes �3-No ❑ 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 />License. ❑ Yes �io ❑ Will be granted � <br />If this application is for a County Board Off Sale Lice se, state the distance in miles to the nearest municipality. <br />State Number of Employees �//�ii ✓ w� �- � G� <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 />1. 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. ,il/J <br />2. 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. /I/ � <br />3. Has applicant, partners, officers, or employees ever had any liquor law violations or felony convictions in Minnesota or <br />elsewhere, including State Liquor Control penalties? �(.Yes ❑ No If yes, give dates, charges and final outcome. <br />S� �-� C'i Tc,° v ���! �' j i �9 � �/.; �9 �� /;.n �7 S <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 />o Yes [�to If yes, attach a copy of the summons. <br />This licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />Check one <br />�3— A. Liquor 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 ineans of support. <br />or <br />❑ B. <br />or <br />❑ C. <br />cei rfi�y fTi <br />Print name <br />A surety bond from a surety company with minimum coverage as specified in A. <br />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 />_ ,, <br />REPORT BY <br />ARTMENT <br />5�� '� -//� <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 />(%4�I� eil �/d �Q �-�I` �f �F' <br />s Department Title <br />Signature <br />PS 9136-(2009) <br />County Attorney's Signature <br />IMPORTANT NOTICE <br />All retail liquor licensees must register with the Alcohol, Tobacco Tax and Trade Bureau. <br />For information call (513) 684-2979 or 1-800-937-8864 <br />