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$. Are the ptemises no �ccupied or to 6e occupied by the applicant enHrely separate and exclusive frotn any other business <br />establishment? es ❑ No <br />9. State whether appticant has or wi[1 be granted, an On sale Liquar Lzcense in conjunetion with this Off Sale Liquor License and for <br />the same premises. ❑�es C-�Io ❑ WiIY be �Zanted <br />1 D. 5tate whether applica t has or will be granted a Sunday On Sale Liquor License in conjnnction with the rcgular On Sa[e Liquor <br />License. o Y'es �o � Wilt be granted <br />] 1. If this applicarion is for a Counry �oa OfF Sale License, staEe t1he distance in miles ta the nearest municipality. 1� �� <br />12. State Number of Emp�oyees �— Xi VY�(�-t�l y! <br />13: Zf this license is being issued by a County Board, has a puhlic hearing been held as per MN Statute 34bA.445 sub2{d}? Il! lI� <br />14: Tf this license i� being issued by a County Boarci, is it located in an nrganized township? If so, a#tach township appro�al. <br />State whether applicant or any of the assaciates in this applicarion, have ever had an application €or a liquar license rejected by any <br />municipality ar state authority; if so, give dates and details. ��/ Q _ <br />Has the <br />license <br />details. <br />:ant ar any of the associates in this aPplication, during the iive yeazs immediately preceding this application ever had a <br />the Minnesota Li.q¢or Control Act revoked for any violat�on ofsuch.Iaws or local nrdinances; if so, give da#es and <br />as app icani, pariners, o�cers, or emp oyees ever a any iquor w vio ations or e ony convyctions in DrI}nnesota or <br />elsewhere, inciuding State Liquor Control penalties? t] �Yes o If yes, give dates, charges and fina] outcome. <br />4. During the ast [zcense year, has a summons been issued under the Liquor CiviI Liability Law (Dram Shop) M.S. 340A.802. <br />o Yes �o lf yes, attach a copy of the summons. <br />"ihis licensee must have one of the fallowing: (AT'�ACH CERTIF[CATE OF TNSiJRANCE TO T��TS FOR�VI.} <br />Chec onc <br />p. I�iquor Liability Insurance (Dram Shop� -$50,000 per person, � 100,OD0 more than one person; $10,000 property <br />destr�ction; $50,000 and $100.000 for loss of ineans of svpport. <br />or <br />❑ B, A surety bvnd. fram a surety company wich rrunim�m coverage as speci.fed in A. <br />6i <br />❑ C. A certi�caee fro�n the State Treasurer that the licensee has deposited wiEh the state, trust funds having market value of <br />$ t 00,Q00 or $] 40,000 in cash ar securities. <br />cer � a. ave reu e a ove ues Eous an a e answers arc rue an correc o m awn . ow e e. <br />Print narne o app icant & tit e 5ignature o A �cant �ate <br />�duaaycl G.1�t'��, VY �ecc�efia � Tv2a�urcv �7l� � Od <br />�EPQRT SY POLICEISI3ERII+F"S EPARTMEN <br />This is Co cer[ify fhat the applicanc and the associate5 named herein have not heen convtcted witl�' che past fi�e years for any violation of <br />laws of fhe Sfate af Jviinnesota or municipal. ordinatices relating to intoxicaring liquor except as £o lows; <br />PolicelSheriff s Department 'Z'itle <br />Signature <br />PS 9136-{200b} <br />County ,Attorney's 5ignanire <br />IMPORTANT NdTIC� <br />All retail liquor licensees must have a c�errent �ederaf. Special Occupational Stamp. This stamp is issued by the BEarea�s of Alcohol, i'obacco, <br />and Firearms. Far information call (651)72G-0220 <br />