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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 />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />S-h:T: G ,-.i.8-. n-F+_ r,VrP`-slc't_j -;" l' 541 ati.� <br />DATE ORGANIZED <br />(cr `f 1 <br />TAX EXEMPT NUMBER <br />CS c)-3.77C') <br />STREET ADDRESS <br />.)-( M cM /v- rug <br />CITY <br />4;:z F—af 00.004- <br />STATE <br />n.l nC <br />ZIP CODE <br />C s 1 / 7 <br />NAME OF PE SON MAKING APPLICATION <br />v l%)h.4)'S L VANS /tisfSc i- <br />BUSINESS PHONE <br />((mil) 9 8"y- 303 <br />HOME PHONE <br />( ) <br />u <br />DATES LI'UOR WILL BE SOLD <br />UDR, WILL <br />• 'K J <br />TYPE OF ORGANIZATION_,._- __ -..... <br />CLUB CHARITABLE CRELIQ10IL. <br />OTHER NONPROFIT <br />LS- <br />ORGANIZATION OFFICER'S NAME <br />MY 4%4y 140w r1 s,"> <br />ADDRESS i ( Sh4' r-1 /LoC l< i ? <br />Ai-A -Ha, t e `i ,t,t k.,. —S <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICERS NAME <br />ADDRESS <br />Location license will be used. If an outdoor area, describe <br />SG r+tn. G-v,,, r_ C)tn€e,t = sc` e.yirc: k, <br />Will the applicant contract for intoxicating Liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Pjo . <br />Will tUg,a � p�plicant/carry liquor liability innp�u�rance? If so, plea sq provide the carrier's name and amount of coverage. <br />a <br />C <br />APROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />/ //JJ ENFORCEMENT <br />L <br />CITY /COUNTY / fit. (/f l 6I <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERIC OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NO fl;: Submit this norm to the city m 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 />