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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101 -5133 <br />(651) 215 -6209 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 />YPE OR PRINT INFORMATION <br />NAME �OaF-�ORGANIZATION <br />4t"ll 42- iiFs..4e. ?e<reAvktor A- 15oe430A <br />DATE ORGANIZED <br />ivAE- 696. <br />TAX EXEMPT NUMBER <br />A9YaG <br />STREET ADDRESS <br />s/Y L f/t. 6...el.( Rd <br />CITY <br />Lt A ,L„ <br />STATE <br />Ali,/ <br />ZIP CODE <br />.5—,57) 7 <br />NAME OFF PERSON MAKING APPLICATION <br />K,I0 000 <br />BUSINESS PHONE <br />(412) $6A 5:34 <br />HOME PHONE <br />0.) yg0 3 /6.f <br />DATES LIQUOR WILL BE SOLD <br />o 1 2. 3 ZUOg <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE REL GIOIJS <br />' L N Pt* 1 ' <br />ORGANIZATIO FFICER S NAME <br />gpc,K 30s5 <br />ADDRESS <br />12 G trya4 51-. Lc. ft7() §-57/ 7 <br />ORGANIZATION OFFICER'S NAME <br />&t b SUC /v <br />ADDRESS <br />02 /0 De 5.40 ;r , LC /yi✓ 1S //7 <br />ORGANIZATION OFFICER'S NAME <br />Nao, cy K ek -Evict r <br />ADDRESS <br />P BSS" Cash Ln Lc_ pate .C.5-4, 7 <br />Location licensefwill be used. If an outdoor area, describe <br />Moe. a.ett 9Ar IS <br />35-a eLi AL L,rfi// Ca.we,. der AU S5--I /7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />MN, c0,Kr- et hde -r witm, ,solo hOn <br />APROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOIIOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUN'1'V OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this torm to the city or county 31) days prior to event. Forward application signed by city and /or county to the a« less <br />a hove. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event <br />PS -09079 (02 /05) <br />2 <br />