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i), <br />_~ <br />____ <br />Minnesota Department of Public Safety <br />v F'r`~DS'ar~; LIQUOR CONTROL DIVISION <br />~„~~~~t <br />o <br />~"~~ <br />,,~ <br />; 444 Cedar St./Suite 100E `~ ; <br />-,~. <br />„ <br />~K~ <br />ia~ „{ ~ St. Paul, MN 55101-2156 ~~ ~° <br />~,, (612)296-6439 "1`DD (612)282-6555 "~a~E.~' <br />~~:r <br />APPLICATION AND PERMIT <br />FOR A I TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />(Organization or location limited to 3 permits in a 12 month period <br /> <br />or <br />TYPE OR PRINT INFORMATION <br />N OF ORGANIZ,~~TION DATE ORGANIZED TAX EXEMP'T' NUMBER <br />' ~,~~~.c~ac,_ Q~.~rr;f~.,., /~;5~:cra.t<'r~.n '~i~~ l`i~ a-`T`97~ <br />z z F hADDt21 ss <br />SIS /,-t9'9t ~~,~_~.~: ~.~.. crrv <br />r-,FFIz ChL~~~ s~rA1I, zm coDE -_- <br />nor' ssll/ <br />NAME OF PERSON MAKING APPLICATION <br />~ BUSINESS PHONE HOh4E PHONE ('~li <br />r D~~s.S <br />iz~ ~ ((~~ O ~~ U i,~ Kea q (c~5 r °140 -3/o.j E~iz .~v1 S3 r8 <br />DATES LIQUOR WILL BE SOLD (I to d days) TYPE OF ORGANIZATION <br />6 ~' 7_ J J_ c%~ S' ^ CLUB t i CFIARITABLE ^ RF~LIGIOLIS i~OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME ADDRESS <br /> <br />2i~u- 7)a 55 _ <br />~~;2- r /'r. 5% - LL, i"~N SS//7 <br />ORGANIZATION OFFICER'S NAME ADDRESS <br />13~_(h S,,y ~ o29~(O I~GSo~~ S7 ~'~' Mnl ~~/i7 <br />ORGANIZATION OFFICER'S NAME ADDRESS <br />FJ c..~i~ k,efi'y, 07 ~~3~ Cc.t'.(, [. c_ IMd s'J/i7 <br />Location wher license will be used. 1f an outdoor area, describe <br />~~ ,~ f it9 c lvl eet ~ o~,. ~ 5 4 ~bl -~ S Sc F~.,, ~ -~ F-t. ~- l.,,l"~ <br /> <br /> <br /> <br />Will the applicaut contract for iutotica[ing liquor sen ices? If so, give the name and address of tLe Liquor license providing the sen'ice. <br /> <br /> <br />Will the applicant cans liquor liability instuauce? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance isuotmandatory) r(1 N ~C>~n~ Uru1<!';.>ri'>'~~~, (. 55s,c~afi2~r <br />APPROVAL <br />.>PPLIC,iTiON IWIIJST SE AFPROVED BY CIT i' OR COLiiv'TY BEFORE SUBTriITTIi:G TO LiQL'OR COiVTROL <br />CITY/COUNTY DATE APPROVED <br />CITY FEE AMOUNT LICENSE DATES <br />DATE FEE PAID <br />SIGNATURE CITY CL,L'RK 012 COUNTY OFFICIAL APPROVED LIQUOR CONTROI, DIRECTOR <br />NOTE: Do not separate these two parts, send both parts to the address above xnd the original signed by this division <br />will he returned as the license. Submit to the Cit}' or Couuty at least 30 da}'s before the event. <br />PS-09079(8/)5) <br />