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�, Are the premises now occupied or to be occupied by the appiicant entirely separate and exclusive from any other business <br />establishment? :�'es . � �++�a <br />4, State whether applicant has or will be granted, an On sale Liquar License in conjunction with this Off Sale Liquar License and for <br />the same premises. :.Xes �i�ia � Will begranted <br />' I 0. State whether applicant has or will be granted a Sunday On Sale Liquar License in conjunction with the regular On Sale Liquor <br />• License. � Yes �I�o � Will be granted <br />� I L If this application is for a County Board Off Sale License, state the distance m miles to the nearest municipality. <br />I 2. State Number of �mployees <br />13. I�this license is being issued by a County Board, has a public hearing been held as per MN Statute 34QA,40S 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 />I. State whether applicant or any of the associates in this application, ha� gv�er had an application for a liquor license rejected by any <br />municipality or state authority; if so, give dates and details. / <br />:. �I�ti l::_ gpj911�911E �:r ,�,� of �ps� a���ia�� ?:� •'�i:, qp��i��llc�n, �•--:ue thc five ��ears imin�tiii:�rclr �rr.:.�T•7�: i�is .�;�i,'��•�i��au c��cr hnd � <br />I�tr f: unJe���h.e'.t�finnewul:� l.l�� �'t�•�I�� i A�r:�-�ukcd f'ur :rm, 4ial�tian al'suci� I;tw s nr f�aeHi o'dm:uiCes' I�,,c1. �14� Q8E�4 ;�lf�i <br />rseLa:lx <br />.S. as app icant, partners, o icers, or emp oyees ever a any iquor aw vio ations or e ony convictions m mnesota or <br />elsewhcre, including State Liquar Control penalties? Yes X No [f yes, give dates, charges and final outcome. <br />d, During the past license year, has a summons been issued undet'the Liquor Civil Liability Law (Dram Shop) M.S. 340A.802. <br />�, Yes I�No lf yes, attach a copy of the summons. <br />'fhis licensee must have one of the following: (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM.) <br />�,heck a�a <br />X� A. Liquor Liability Insurance (Dram Shop) �$50,000 per person, $100,000 more than one person; $10,000 pr4perty <br />destruction; $50,000 and $100.000 for loss of ineans of support. <br />E3. A surety bond from a surely company with minimum coverage as specified in A. <br />� C. 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 />i�►� rC � P� C airc uwrs N � x� r4 an rirrfr� iF nrr aiwn ri �f. <br />'r�fu n0uit• r. ,x�i ;,ir-- i-i-� h.�imi•_ •i •,fi�x�w�� �.�r <br />� � � •- <br />UaT�iel R, f;r�aimt�r;; �.�� y O i� I'�} 2��1'Cl <br />RFF[�1t� $�' F ",l►kIF.AIFir`$ b F�kRT�Wi{f+l'1 <br />� <br />1'his 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 />?oiicelSherit�s Department Title Signature <br />PS 9136-(2003) <br />Cottniy Attorney's Signature <br />IMPORTANT NOTICE <br />All retail liquor licensees must have a current Federai Special Occupational Stamp. This stamp is issued by the Bureau of Alcohol. Tobacco, <br />and Fir�arrns. For informationcall (651)726-0220 <br />