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~i`t ij ~~ <br />,,:E `°` °~a ~ , i <br />P ~``'~, <br />'<\1 Minnesota Department of Public Safety ~• <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION ~~ ~ ' '~' <br />\ ~/ ~ <br />`~~ .p% 444 Cedar Street Suite 133, St. Paul MN 55101-5133 '' t '~~ <br />-- ~,. <br />~~`~""~~~ (657) 215-6209 Fax (651) 297-5259 TTY (651) 282-6555 v~=; <br />-"--- W W W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FORA 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION DATE 0 GANIZED TAX EXEMPT NUMBER <br />f 4 _ t p(1 r <br />.~7s.i <br />•~" 'c' ~' <br />ie <br />u<c-~L- (et <br />~ISS~~c~ ~' <br />)v. <br />~`iG <br />f~°a ' <br />~.`/'~~G° <br />,. <br />n <br />c- , <br />-< Z <br />_ <br />STREET ADDRESS CITY STATE ZIP CODE <br /> <br />NAME OF PERSON MAKING APPLICATION BUSINESS PHONE HOME PHONE ti°~ I( <br />Ki~f- li~j`> (45t> lG4 C~- 1 iLJII '-f°rt.aiG S' L ~'ei.• , <br /> <br />DATES LIQUOR WILL BE SOLD <br />H (3 <br />S ~ <br />~~'1' TYPE OF ORGANIZATION ._ _ <br />~ <br />C' .L B T <br />T P T~ <br />ORGANIZATION OFFICER'S NAME ADDRESS _ R`-~""^""'~" " <br /> ~.L ao•t-jd. !I/~ 5 <br />ORGANIZATION OFFICER'S NAME ADDRESS ° <br />~' ~ t 54' l'"fu ,1.~r'E~~ i)t~c;l~t 5Y L,~°~~ C`c.~-e:~.: i'vbv S~/i7 <br />ORGANIZATION OFFICER'S NAME ADDRESS <br />r <br />~%4~.c-/ ~~'R'7K94~i~ <br />.~-$~Y7 ~~~rt. f.td Er'~~1~ ~m~~c,~ /lir~' JS{1•~ <br />Location lice Ise will be use <br />d <br />. If an <br />outdoor area, descr <br />i <br />be <br />~~ <br />~~ii <br />[ <br />\t>I•zi: (c; Yt1. Li~i' ~ <br />( <br />r /~ / <br />I~I'c' t ,~_,n,i=,f ri tiI Nl ) )~l7 <br /> <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br /> <br />Will the applicant carry <br />liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />nn+, <br />!Y7 /J 4~G ..~~ U11 <br />t <br />~.t%,' UNI~I`•"~'I 9y F~§4~i "f.. a!-'~~F/' <br /> ~ <br /> APROVAL <br />APPLICATION MUST B1; APPROVLD BY CI TY OR COUNTY BEPORI; SUBMITTING TO ALCOI30L & GAMBLING <br /> 1;NPORC)iM1';NT <br />CITY/COUNTY DATE APPROVED <br />CITY FEE AMOUNT LICENSE DATES <br />DATE FEE PAID <br />SIGNATURE CITY CLLRK OR COUNTY ORRICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NU'I'E: Snhmit this corm to the city or emmty 3U clays prim-to event Forward application signed by city and/or county to the address <br />above. If the application is approved the Alcohol :md Gamhlin~ Entm~cement Divisim~ will return this application to he used as the License tm~ the event <br />,~ f~ <br />iI <br />PS-09079 (02/05) <br />