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SEP -19 -2011 09:59 From: <br />To:97664048 P.1 <br />Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />+I44 Cedar Street Suite 222, St Paul MN 55101 -5133 <br />(651/201-7S97 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 DAB'" TEMPORARY ON-SALE LIQUOR LICENSE <br />TYPE OR PItIN'I' INFARMA'I' <br />y < sys pnm to overt. pm ward - .yppitcanon signed by city an to county to the addross .. <br />above, If the application IB RI/proved the Alenhnl Am) Gambling Iinfmrawmlt Division will return thin application to be unit as the License for the coral <br />Ps- 09079(12109) <br />NAME. OF ORGANIZATION <br />Saint „John 1a Church of Little Canadc <br />DATE ORGANIZED <br />1851 <br />TAX EXEMPT NUMBER <br />ES 23330 <br />STREETADDRFSS <br />380 Little Canada Road East <br />CITY <br />Little Canada <br />STATE <br />Mn <br />ZIP CODE <br />55117 <br />NAME OP PERSON MAKING APPLICATION <br />Rev. DDqavidltKoh3gneeLLr <br />BUSINESS PHONE <br />(,51) 484 -270.8 <br />HOME PHONE <br />651) 335 -9164 <br />DAT NO IQewber 120.RT•ib 11D <br />TYPE OF ORGANI'LATIUN <br />Cll(UR CHkR1TJ}}3LE RN, CIOUS OTHER NONPROFIT <br />ADDRESS <br />380 East Little Canada Road Little Canada, <br />5 <br />URBANIZATION OFFICER'S NAME <br />Father David Kohner <br />ORGANIZATION <br />OFFICER'S NAME <br />ADDRESS 51 1 7 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location license will be used, If an outdoor are , t escribc <br />School gymnasium Mena Club Turkey Bingo <br />Will the applicant contract for intoxicating liquor servico7 If so, give the name and address of the liquor licensee providing the service, <br />Will the applicant early liquor llability insurance? If cc, please provide the carrier's name and nmmmt ol'coverago. <br />yea Catholic Mutual. <br />APPROVAL <br />APPLICATION MUST Bt APPROVED BY C1'I`Y OR COUNTY <br />ENFORCEMENT <br />CITY/COUNTY <br />BEFORE SUBlYDTTING <br />DAII.B APPROVED <br />LICENSE DATES <br />TO ALCOHOL <br />& GAMBLING <br />CITY PEE AMOUNT , <br />DATE FEE PAID <br />iscNATURE CITY CLERK OR COUNTY OPP}C}Ax, APPROVED DIRECTOR ALC01101., AND CAMRLINC ENvoncrmEN'I' <br />NOTE: Submit tills form to tllo city or count 30 1 <br />y < sys pnm to overt. pm ward - .yppitcanon signed by city an to county to the addross .. <br />above, If the application IB RI/proved the Alenhnl Am) Gambling Iinfmrawmlt Division will return thin application to be unit as the License for the coral <br />Ps- 09079(12109) <br />