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ae4~ J Ni .C S <br /> j-Sg ~~n Minnesota Department of Public Safety ~ <br /> 1 r ALCOI IOL AND GAMBLING F,NFORCCMGNT DIVISCON <br /> e ~ 4~4 Cedar Sweet Suite 222, St. Paul MN 55101-5133 "'~%V <br /> . <br /> - . (651) 201-7507 Pax (GS I) _97-5259 TTY (651) 282-6555 t~R~ <br /> W W W.DPS.S'fAT[:.MN.US <br /> APPLICATION ANC) PERMIT <br /> FOR A I T04 DAY TEMPORARY ON-SALE LIQUOR LCCENSE <br /> 'T'YPE OR I'RIN'f INI'ORMA"LION <br /> <br /> NAMI'i OP OR(iANfLATION DA'Z'E OIZGANII.I'sD fAX EXGMPT NC1Ml3[itt <br /> .~i . v ~a~~J %~'k`. ~V:~-, i GF1..1~5 ~7`Y r t_l c~ ,l > S S C; <br /> S"iRE1"I' ADDRESS CITY S'1'A'fl: LIP CODE <br /> ~(?,j-( ti't c~;~.1/'r„C~~ y ~.t~- f x, ~ ~''1 ti .S!'S i / "7 <br /> NAME OP P[:I(SON MAI<IN(i APPLICATION 13USINI>SS PI-TONG; 1-IOMH PHONE <br /> .J6<•rr~ ~ic,•„rc cGl~ k~73• ~7)tc~ t,~r)...77(C..,z.rc/ <br /> DA'i'[:S i,t000R W11.,1.,131i S01.,D n.„ "I'YPL:OP OR(iANI%A'I'ION <br /> 0 / ' , 11 :-IA 21'I' 131.,P I~1, (?I )I Iq' 01'tIPR NONPItOL~'1' <br /> OKGANILA'I'IONOPPICER'SNAME AI)DRI?,SS <br /> % / ~ <br /> %i~'~-hr~~ nFFt'~0 wia/~J~~~. > d21 L_l7L%- C.;9r~fa-il.~ dCL), !_;,rT~.e= G~v/-I~.Ar~u~ <br /> ORGANiLA'1'ION OFPIChI~ S NAMI: AI)DRISS <br /> MFLt2~ /1 ~Oi.~~ /an~S Si"IZ.~ <br /> ~ ~:,:1-.~4 t9,~! J rJ i17 <br /> OR(iAM%A'PION OPPICFiR'S NAtvtl ADI)R[SSS <br /> t.,oattion license will be used. I1'an outdoor area, describe <br /> C/'l7/t2L~-l.. <>'}9'Y7NJ2.T. ^iYi .S ~i/)r`1'C.r ~ SC~ii'OCL (~/v Fk J.l:ays... ~l liC 7...i.)OF.9l~. i~_~C~G/L_ <br /> Jl,,%` L i L, S'!I at, t ~r~- lJ /'C/iv~{-~s'~'us N' <br /> Wili the apl,~licam conu~tet for intoxicating liquor service? II'so, give the name and address of the liquor licensee providing the service. <br /> ~(if7 <br /> Will t}le applicant carry liquor liability insurance? If'so, please provide the carrier's name anti amount of coverage. <br /> ~4)~. in~S'cc.:"~~',0 >7~`~vtKsH J~'~GlyaJ;'~jCr!"5~ ~rF' S'~_ ~'i1-ct~ t,°<--S <br /> /~2vn'~~n^ /l~rk..;N1'S~Jt_F~ !7-/;iz.ort.~r-r ~,Ft f7-I-oz,.cC ~~t~ u tz•~.:tz. <br /> APPROVAL <br /> APPLICATION MUST BE APPROVIsD BY CITY OR COUNTY BBt:ORG SUBMI'fTfN'C 9'O ALCOHOL S. GAMBLING <br /> CNPORCGMCN'I' <br /> CITY/COUNTY DATEAPPROVED_ <br /> CITY FEL-' AMOUNT' LICENSE DATES <br /> DATE FLE PAID <br /> StGNA'1'URIi CITY Chk:RIC OIi COIIN'{'1'O(~GICIAh API'ROYIiD DIRIiC'I'OR AI,COIIOL AND GAMBLING IsNFORCIt~1CNT <br /> NO'1'1.'s: Submit this fm•m fo the city or county 30 Jays prim• to event. C~orwm'd applicatinn signed by city and/or county to the address <br /> above. If the application iz approred the Alcohol and Gambling finforcemenl Division gill return this application to be use<I as the License for the event <br /> PS-09079(12!09) <br /> 3 <br /> <br />