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Minnesota Department of Public SaI<:ty <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite IDOL <br />St. Paul- 1' [ 55101-2156 <br />(612)296-6439 LDD (612)_32 -65;5 <br />AP'PL (.AT.ION AND PERMIT <br />FOR A iTO4 DAY TEMPORARY .YlP JR-`,aARS' O\ S5. .. _: ICE OR LICENSE <br />'SE <br />(i)r iari/ation or location ;mlte:I O 3 )e:nu(s in a 1: _'Month <br />or <br />TYPE OR PRINT INFOPJvLATION <br />NAME OF ORGANIZATION <br />/- , 1 i t C�r G » ztc cL '&2,c .Th.f.41-,t :2 li. ss i to J <br />DATE ORGANIZED <br />1 `% 1,0Z <br />TAX EXEMPT NIJMI3ER <br />02 % .12 G <br />SIREETADDRESS <br />15 L, /-)t G -'- c .. La - <br />CITY <br />Lf'flt Lc -L,LL <br />STATE <br />Ili >✓ <br />ZIP CODE <br />s._-ii7 <br />NAM A.pF PE2.SON NI/LIKING APPLICATION <br />l *- k iia Ss <br />BUSINESS PI-IONE <br />6S1 764, -'iZJ iQ <br />HOME PH NE <br />(65-7) Litie -__l hS- <br />DATES L QUOR WILL BE SOLD (1 to 4 days) <br />0410±. a(9) aa07 <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE 0 RELIGIOUS i OTHERNONPROFIT <br />. <br />ORGANIZATION OFFICER'S NAME <br />'W,LL V— 13'655 <br />ADDRESS <br />72 L bryiti� 5— 4- .0 ,4i,u 5.57/ 7 <br />ORGANIZATION OFFICERS NAME <br />I3a- \) 45` q. -.cw' <br />ADDRESS <br />2'iL Go Desofu ST, !Lc M - x' 7 2 <br />ORGANIZATION OFFICERS NAME <br />tVC'- i Ke.cstie i, <br />ADDRESS <br />X 885 co5fit Ln : L -c. ,Yl,✓. 55777 <br />Location wlieie license will be used. If an outdoor area, describe <br />1 P,- an.e -zr tee; K L1..tY -,. <br />Ce -.-4, ix J 5-.37/7 <br />ToaRv4in e.gH <br />id-k M /J <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />I <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) %fin • Jo, ,.,,t LC•n i-e-(' t.. , i,.& 4 S 5 e. ccihan <br />I APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />1 CITY /COUNTY <br />DATE APPROVED <br />LICENSE DATES <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />APPROVED LIQUOR CONTROL DIRECTOR <br />NOTE: Do not separate these two parts, send both parts to the address above and the original signed by this division <br />will be returned as the license. Submit to the City or County at least 30 days before the event. <br />PS- 09079(8/95) <br />