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OTH�R INFORMATIDN <br />�Yes ❑ No 1. Has the applicant or associates been granted an on-sale nan-intoxicating mait beverage (3.2) and/or a"set-up" <br />Ircense in conjunction with this wine license? <br />❑ Yes �0 2. Is the applicant or any of the associates in this application a member of the counry board or the city council, <br />which will issue tEiis license? If yes, in what capacity? .(IfEhe applicant is <br />the spouse ofa merr�ber of tE�e gaveming body, or another farrEily relationship exists, the member shall not voie <br />on this application.) <br />� Yes -�1No 3. During the past [icense year, has a summons been issued under The [iquor civil liability (Dram Shop) {M.S. <br />� 34QA.802). If yes, attach a copy af the summons. <br />�Yes �10 4. Has appiicanT, partners, officers or empioyees ever had any liquor law viol.ations in Mi�esota or elsawhere. <br />1f so, give names, dates, violations and final autcome. <br />GYes �10 5. Does any person other than the applicants, ltave any right, title or inEerest in the fUrniture, fixTUres or equipmenT <br />in the licensed premises? If yes, give names and details. <br />GYes �No 6. kIave the applicants any interests, directly or indirectly, in any other liqUOr establishments in Minnesota? If yes, <br />give name and address of the establishmen#. <br />I CERTiFY THAT I HAVE READ THE ABOVE QUESTIONS AND THA"�' THE NSWERS AItE RUE AND CO TO THE <br />BEST OF MY OWN KNOWLEDCsB ` ,� — %� <br />c_--------- -� .__,� .�� .{� �� ^! r s 9 �n � �i � !�7 � 1 a �� <br />The licensee must have one of the following: (cneck o�e) <br />� A. Liquor Liability Insurance (Dram Shop} $SO,OQO per person; $100,Q00 more than one person; $10,000 praperty destruction; <br />$50,000 and �100,006 for lass ofineans ofsupport. ATTACH "CERTIFICATE OF INSURANCE" TO THTS FORM. <br />u B. A Surery bond from a surety company with minimum coverage as specified above in A. <br />= C. A certificate from the State Treasurer that the Licensee has deposited wirh the S#ate, Trust Funds having a market value of <br />$IOQOQO or $140,000 in cash or securities. <br />IF L,ICENSE IS ISSUED BY TF�E COUNTY BOARD, REPORT OF COUNTY A'i'TORNEY <br />�Yes ❑No 1 ceriify that to the best of my knowledge the applicants named above are eligible to be licensed. <br />If no; state reason. <br />Signature County Attorney County Date <br />REPORT BY POLICE OR SHERIFF'S DEPARTMENT <br />This is to ceetify that the applicant and the associates, named herein have not been convicted within the past fi�e years for any violation of <br />Laws of the State of Minnesota, Municipal or County Ordinances relating to IntaxEcating Liquor; axcept as follows: <br />I Signature Deparlment and Title Date <br />' IMFORTANT I�OTICE <br />ALL RETAIL LIQUOR LiCENSEES M1JST HAVE A CURRENT FEDERAL SPECIAL OGCLJAATIONAL STAMP, fiOR <br />INFORMATION R�GARDING OBTAINING THIS STAMP, CONTACT THE BUREAU OF ALCOHOL TOBACCO AND FIREA�MS <br />AT (bS 1) 726-0220 ._. (PS9114-2006) <br />NOTICE <br />A 530.00 service charge wi[t be added to all dishonored checks. You may also be subjecteci ta a civil penalEy of $10i1.00 or 100% of the value of t�e check, <br />whichever is greater, plus interest and a#torney fees. <br />