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0 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 />_ __ <br />� Yes �No Have the applicants any interests, directly or indirectly, in any other liquor establishments in Minnesota7 If yes, give <br />name and address of establishment. <br />I�EF?TIFY Ti�a��' I F��VE 6iE�� "ili� �B�CD�i� QUESi1�3�[S ANI� i�l�:i T�qC: �fUS�tlE�S I��E TRIiE l��� CC��R��i i� T'W� �E�7 CS� M°� <br />K�(JWi��CJ��. <br />` i� � i `� l �'i� �� <br />Signature of Applicant Date <br />The licensee must have one of the following: <br />Liquor liability insurance (Dram Shop) $50,000 per person; $100,000 more than one person; $10,000 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 />�' <br />A certificate from the state treasurer that the licensee has deposited with the state, trust funds having a market value of $100,000 or <br />$100,000 in cash or securities. <br />IF LICENSE IS ISSUED BY THE COUNTY BOARD, REPORT OF COUNTY ATTORNEY <br />OX Yes � No I certify that to the best of my knowledge the applicants named above are eligible to be licensed. If no, state reason. <br />Signature County Attorney <br />County Date <br />REPORT BY PQLICE OR SHERIFF'S DEPARTMENT <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 <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$30.00 service charge will be added to all dishonored checks You may also be subjected to a civil penalty of <br />$100.00 or 100 % of the value of the check, whichever is greater, plus interest and attorney fees. <br />Page 2 of 2 <br />