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�] Yes }�No DoeS any person other than the applicants, have any right, title or interest in the furniture, fixtures or equipment in the <br />licensed premises? If yes, give names and details. <br />� Yes [Vf No Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota? If yes, give <br />name and address of establishment. <br />I CERTIFY THAT { HAVE READ TFtE ABOVE QUESTIONS AIVD THAT THE ANSWERS ARE TRUE AND CORRECT TO THE BE57 OF MY <br />KNOWLEDGE. <br />Oc��ai�l� <br />Signature of Applicant Date <br />The licensee must have one of the following: <br />�((,iquor liability insurance (Dram Shop) $50,000 per person; $100,000 more than one person; 510,000 property destruction; <br />$50,000 and $100,000 for loss of ineans of support. Attach "CERTIFICATE OF INSURANCE" to this form. <br />(`. A surety bond from a surety company with minimum coverage as specified above in. <br />r, A certificate from the state treasurer that the licensee has depasited with the state, trust funds having a market value of $100,OOo or <br />$100,000 in cash or securities. <br />— —_ _,........, NEY <br />IF LIGENSE IS <br />�X Yes ❑ No l certify that to the best of my <br />Signature County Attorney <br />BY THE COUNTY BOARD, REPOf <br />�dge the applicants named <br />County <br />iRT BY POLICE OR SHERIFF'S DEI <br />TTOR <br />are eligible to be licensed. If no, state reason. <br />ENT <br />Date <br />This is to certify that the applicant and the associates, named herein have not been convicted within the past five years tor any <br />of laws of the State of Minnesota, Municipal or County ordinances relating to intoxicating liquor, except as follows: <br />Signature <br />Department and Title date <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 />A 530.00 service charge will be added to all dishonored checks You may also be subjected ta a civil penalty of <br />5100.00 or 100 % of the value of the check, whichever is greater, plus interest and attorney fees. <br />Page 2 of 2 <br />