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l \'n' nrz ur <br />Minnesota Department of Public Salety <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 />WW W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A I '10 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />\FORMA "IION <br />NAME OF ORGAN! Z:AT ION <br />l_I 7-ccii C'A „1 n-'> A ` ec.%E4i/on; /ASSC) <br />DATE. ORGANIZED <br />3--,,,,.s i (I6 L <br />TAX EXEMPT NUMBER <br />2_ 9 Lf a ( ) <br />S(REEr ADDRESS <br />S /.S' L/7'rc6 C4'N-I,A bvk <br />CITY <br />LeTTLE(idtn. <br />STATE <br />M rj <br />ZIP CODE <br />'S-S- if 7 <br />NAME OF PERSON MAKING APPLICATION <br />,3/4.0ti'N -1 'ZveL yIA 61,x)SK1 <br />BUSINESS PHONE: <br />Ibs' /)4 6- 7066 <br />HOME PHONE Cw C.C. i xs:-/ <br />4"Sileis7416470 26.d 2Yh7 <br />DATES LIQUOR WILL BE SOLD <br />-- (AL'-j -e`l e 31 20l ( <br />TYPE OF ORGANIZATION <br />CI .t,;13 CHARITABI,F RELIGIOUS aHI I2NONPROJ'Ll' <br />(' <br />ORGAN)ZATON OFFICERS NAME <br />Tm0-01v- 2Prgetneu /J <>lcl <br />ADDRESS ))C) Li CEF_uJ.9tZA jJ( 1 <br />t/ Ire- 64- „,,4"D.4 21,J SS / 0) t <br />ORG \NIZA1 ON OFFICER'S NAME <br />n- rvl Atv ; ) A ( o C e L.,4 N ' <br />ADDRESS 1 o cl eLv,(.J (i) b F.0 <br />b rr( & . C,47\J A t )t\ M,\1 , & i 1 ) <br />ORGANIZATION OFFICER'S NAME <br />i\iANICLI t; H0d,OE- <br />ADDRESS -y `i 6 ��ilcLE6 -LZ L AI <br />'JA>N/1 -is t+L.Iw,rrs M,J S5-11-7 <br />I.,ocation license will be used. If an outdoor area describe <br />Leo LL-S'/ 8,t L. 0 err-1764 /;1Atc 16044nfrlisAii_ <br />PDO F-(2, 0112, L/rrc.EL (4 1464 e44 Ss)17 <br />Will the applicant Contract 101 intoxicating liquor service? If so. give the name and address or the liquor licensee providing the service. <br />j� (.) <br />will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />C.OtPtxvL. 1I1I)£(\'Ai\Jir1 Co P� Pawl .is C.PC�i314&!iZ. t raOdicizc'. <br />( APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROV <br />LICENSE DATES <br />TO ALCOHOL. <br />EiD <br />_. <br />& GAMBLING <br />CI"T"Y FEE. AMOUNT <br />I)ATIi'. FEE PAID <br />SIGN :'fCRE CIrA CLERIC OR COUNTY OFEICIAI, APPROVED DIRECTOR :u_cottot.Am) GAMBLING ENFORCES! ENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and /or county co t11c address <br />above. If the spplieatinn is approved the Alcohol and Ganimint Enr n:CIO nt Division will return this application to be used as the Litcnse I'orr the es Ent <br />I'S.09079 12 i,nl, <br />4 <br />