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Minnesota Depattuent 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 W <br />W W.DPS. STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />I41C' (Anal& ar14/ildll n ” S(_, . <br />DATE ORGANIZED <br />1t:)./17/lc'17& <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />51 F= LL —le Ca11atict,126 <br />CITY <br />1-1 - 1e —Carak <br />STATE <br />Mk) <br />ZIP CODE <br />551 /7 <br />NAME OF PERSON MAKING APPLICATION <br />San !liaison <br />B158tNBSS PHONE 0_,60... <br />(01)7`i3 -3703 <br />HOME <br />(6. /)`fS3 <br />PHONE <br />`I 4( <br />DATES LIQUOR WILL BE SOLD /nI,^,� y <br />t u u51 3 -0 cioO7 <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOUS �OTi <br />ADDRESS <br />-70. I abo -m_. A, LI#h 6na <br />-IF.R NONPROFIT I', <br />ORGANIZATION OFFICERS NAME <br />5Aalh Ne- 15011, Pres/4enF <br />ti, m Ai x/17 <br />OORGGANIIIZATION OFFICERS NAME <br />(?Pekin t <br />(A5 <br />ADDRESS <br />a ,ny eit / j4 L jh db.., MA 7 <br />ORGANIZATION OPES, NAME <br />1-11M1.41 6a-the/Ziff? ,-1-1 (iSCfif - <br />, , <br />ADDRESS <br />,Linz i 5F - �I4,6-1 -11Ne eakvaeL, iw 1/3 <br />Locdtion license will be used. If an outdoor area, describe <br />(Spooner Park. 3 'i F1, 4 L1'-i{-P_ Gogh mAi 551/7 <br />, <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 />ill innr'SnftL.7 ml- all i &xwn'h , Assn. <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 ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOT);: Submit this term to the city or county 30 days prior to event. Forward application signed by city and /or county to the address <br />above. 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 />