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Are the premises now occupied or to be occupied by t�e applicant entirely separa�e and exclusive fi•om any other business <br />establishment? CYes �No L(,?(��-��y� /f� ��(����i'1G'( (,�',/"1-�'�P"�����i'�'"iG�l'I <br />State whether applicant ias or will be grauted, an On sale LiquoiiLicense in coi �unction with this Off Sale Liquor License and for <br />the same premises. -�Yes �No '� Will be granted <br />. State whether applicant has or will be granted a Sunday On Sale Liquor License in conjtmction with the regular On Sale Liquor <br />�' License. C Yes �No C� Will be granted ,� <br />ll. If this application is for a County Board Off Sale License, state the distance in miles to the nearest municipality. � d��F <br />12. State Number of Employees �j '"' d.�% <br />13. 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 />14. 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 tl�is application, ave eve^r'had an application for a liquor license rejected by any <br />municipality or state authority; if so, give dates and details. �� "/� � <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. ►°���} •—/li` �� <br />� <br />;. Has applicant, parhiers, officers, or employees ever had any liquo� 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 />4. Dw•ing th,e past license year, lias a summons been issued under the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br />C Yes �No 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 l�iZl (�'�_ i ei/��C f IF�J � �L� �� �, � (� �,�� �� C�.— � � � "T i� "�7� �' �li �6"'Gl f� L�.� <br />V �� <br />� A. Liquor Liability Insurance (Dram Shop) -$50,000 per person, $100,000 more than oue person; $10,000 property <br />destruction; $50,000 and $] 00.000 for loss of ineans of support. <br />or <br />C B. <br />or <br />-' C. <br />ce� <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 />l'� %� ` ��G' C'�i"� I <br />REPO T BY PO <br />answers are true ana correci oi my own <br />DEPARTMENT <br />ate <br />_ ��'"'/S <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 />,Q���V 1`2 L� f�C�G ZZ�., �D�'Pl� <br />Police/Sheriffs Department <br />CIf� � �- f= P��L�t^z� <br />Title <br />Signature <br />PS 9136-(2009) <br />County Atto�ney'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 />