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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St, Paul MN 55101-5133 <br />(651) 201-7507 Fax <br />297-5259 TTY STATE MN USG51j'282-GSSS <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />L <br />STREET ADDRESS <br />NAME OF PERSON MAKING APPLICATION <br />3.7 <br />DATES LIQUOR WILL I3E SOU) <br />ORGANIZATION OFFICER'S NAME <br />o > <br />ORGANIZATION OFFICER'S NAME <br />OROA IZATION OFFICER'S NAME <br />Location license will be used. If an outdoor area, describe <br />oNs <br />DATE ORGANIZED TAX EXEMPT NUMBER <br />29 4-1 (o <br />(A' i4.J lc <br />CITY <br />L e <br />Co, <br />BUSINESS PHONE <br />'32 / eit <br />TYPE OF ORGANIZATION <br />ADDRESS <br />3 t) <br />ADDRESS <br />ADDRESS <br />ZIP CODE <br />5 -51/1 <br />-- <br />HOME PHONE 1 /4/ <br />1_,014 -Its, 1 y 71 <br />J <br />Will the applicant contract for intoxicating liquor service? If so, sive the name and address of the liquor licensee providing the service, <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage., <br />ivy <br />APPROVAL <br />APPLICATION MUS"I' BE APPROVED I3Y CITY OR l COUNT M NTORE SUBMITTING TO ALCOHOL 84 GAMBLING <br />EDATE APPROVED <br />!) <br />CITY/COUNTY <br />CITY FEE AMOUNT <br />DATE PEE PAID <br />LICENSE DATES <br />SIGNATURE CITY CLERK OR COUNTY OPPICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address <br />above, lithe application Is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the cvi' <br />PS•09079(05106) <br />