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NAME OF ORGANIZATION v <br />c/ lailid Fi+( ffi i/Ati,;c.Yi- rs <br />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />6 l c Mi Ctir Y 5•; <br />c TV <br />c, ,.9-0/t <br />STATE <br />AI A <br />ZIP CODE <br />s S <br />NAME OF PERSON MAKING APPLICATION <br />fol +ti 11,A 6,)K <br />BUSINESS PHONE <br />(6 1 d) $73.77I0 <br />HOME PHONE <br />(QS J) 77(0•-,) -`Xo <br />DATES LIQUOR WILL BE SOLI) <br />h& I d l <br />TYPE OF ORGANIZATION <br />CLUES CFLARITABI E zfi, <br />OTHER NONPROFIT <br />t <br />LkA,J 1 <br />ORGANIZATION OFFICER'S NAME <br />r <br />Rnic /S! "/a Yo /'1-»e/ <br />ADDRESSi r <br />S iL_ <br />7�^ <br />G.T T c:"..) <br />ORGANIZATION OFFICER'S NAME <br />1 <br />M -rcy K4+'Y (w,,,,At <br />ADDRESS l <br />v..E 3-( tACM a/ at <br />G-Sr-Lur caw-) A()/a- i r■-■.a) S 15 1 (7 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location license will be used. If an outdoor area, describe <br />(14-64.6! et-t- .5ak.9t c /GJZ.rr)a .s7'r-3 -c( /4„, in Sabct. MAi4 --J L(2,, <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />NO <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. p <br />6 <br />yes T ICS Cie! -1) 77-0, ;?G11,0CyCi<Se 0,c- _Si.. /�A/n 4 tAfA S <br />.S��L, <br />A..-0/0 z N v r e 6 CA-tO u -G. /i vi'� SPA 4 GNI"o9 G r <br />APPROVAL <br />APPLICATION MIDST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK 011 COuN'ry OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, St. Paul MN 55101 -5133 <br />(651) 201 -7507 Fax (651) 297 -5259 TTY (651) 282 -6555 <br />W W W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />2 <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or cou t the a d d ress <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this a pplication to be used as the License for the event <br />PS- 09079(12/09) <br />