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Minnesota Department or Public Salety <br />ALC01 °101_ AND GAMBLING ENFORCEMENT NT DIVISION <br />444 Cedar Street Suite 22? St. Paul MN 55101.5133 <br />(651) 201 -7507 Fax (651) 297.5259 TTY (651) 282.6555 <br />WW W.DPS.S'FA1'E.MN.US <br />APPLICATION ANI) PERN4IT <br />FOR A I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />rv1>r: nu ) P n!1 ix: Fan'n e rn ns <br />NAME OF ORGANI 7A'I'I ON <br />LI Sic (A.-1 (\-.'D A ?Ea EA noN ASSD <br />DATE ORGANIZED <br />SL.,,N 1 (i b t. <br />TAX EXEMPT NUMBER <br />•-- 9 `I' 2 <br />STREET ADDRESS <br />Sr.S' L, Tc_l C4niA DA .Gf <br />CI'T'Y <br />L, TILE ('4419' <br />STATE <br />(14 1'; <br />ZIP CODE <br />' :3--Si17 <br />NAME OF PERSON MAKING APPLICATION <br />' I)vvvrtil 2t\- L' 3;4'JSKi <br />BUSINESS PI-IONE <br />(6/)4&-7O6 <br />11059E PHONE F 6 L.,- 63: / <br />I6,--915<57`APO 2%d 2267 <br />DATES LIQUOR WILL BE SOLD . 2(% C t <br />1�" ' <br />'TYPE OF ORGANIZATION <br />CLUB CFI 4RJJAl31 F RPI GEpt:S (CPFIER NO`: PROD 12 <br />ORGANIZATION OFFICER'S : ME <br />T'O bait 2A4g„n(Ai, .)5) Ck <br />ADDRESS .)) 2.1 Of_rct2/9O i• ✓n f- - -_l <br />t, rct6 CrA,wW.t /5'44 / Sc' i <br />ORGANIZAI ONOFFICER'SNAME <br />ft-rvirtr.;7 ,4 ()IOC E LA i \I <br />/�vC� <br />ADDRESS I0 Cj (3L_AAcjioD b 4V <br />b Tr( G Cff-••.tA im M Nl :ST/ 1 ) <br />ORGAN'I %AT ION OFFICER'SNAME <br />1vlaNI0L1 yHOCtbE.> <br />ADDRESS 7L!6 C;%.Zc &/} -r.{ L4 <br />JEIa1J/I-IS 1--+.v, 'trs N/N Ssri.7 <br />Locution license will be used. If an outdoor area, describe ) }4 L.COtoted /! 4J /CE. <br />')-6,2- c NC:. /14L,JG,ny Ct L/ rTU Cfi d 6 ib/1 M4 637/ 7 <br />Sr JDId -AS SC(-IO &L 6-V 0A. <br />will the applicant contract I'or intoxicating liquor service? I iso. give the name and address of the liquor licensee providing the service. <br />NC) <br />Will the applicant tarry liquor liability insurance? Irso, please provide the carrier's name and amount of coverage. <br />C.n P \TVL_ 11\ ..e. A,1/4)IT1 (DV Peaty. CP0131 y!w /Z i <br />E 70/a) <br />APPROVAL <br />APPLICA'F'IO1iN MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CI'FY(COE.,NTY <br />CITY FEE AMOUNT <br />BEFORE SUBMIT" I'ING TO ALCOHOL & GAMBLING <br />DATE APPROVED — ... -..... <br />LICENSE'; DATES <br />DATE FEE PAID <br />SIGNAICEiEC an CLERK OR COUNTS OFFICIAI. APPROVED DIRECTOR ALC'OIIOI. :U D GAMBLING ENFORCEMENT <br />ddreei <br />NOTE: Submit this form to the city or county 30 days prior to event. I'orw'art app ltcauon signed by etty nndlot wunt7 to t to a .. <br />above. If the application 7s approved the Alcohol and Gambti ng Enforcement Division will return this application 10 be used as the License fur the 0ve111 <br />I'S -O°07') 411 q5i <br />8 <br />