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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 />WWW.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 />SPo4STnEN -5 Luke) .NL. <br />DATE ORGANIZED <br />2.000 <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />'Z9 N 3 QttAi nz N' <br />CITY <br />Ul ti . L&naa <br />STATE <br />M tJ <br />ZIP CDE <br />5-6-1 1 <br />NAME OF PERSON MAKING APPLICATION <br />tor! Go IA) rn,q() <br />BUSINESS PHONE <br />(LS/)i`l000`AS— <br />HOME PHONE <br />‘51)L{90Dovr <br />DATES LIQUOR WILL BE SOLD n i4 it / Lo 2 D 04 <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOUS <br />OTHER &ONPROFIT) <br />ORGANIZATION OFFICER'S NAME <br />�D 4 �JDWY 4h/ <br />ADDRESS <br />Z.q \3 Pn�n s N. L4TL, CAP-A,ii4 n p) 3-57/7 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location license will be used. If an outdoor area, describe <br />PIohee f Park con -Ee41 ux R,D <br />Lyle Gc,Aci nvo s---s-1) - <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Nu <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />inn) to) NI- L4J`D69.- WKLTIN.& A-S6oCkAlloN <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 />NOTE: Submit this form 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 />05 -09079 (02/05) <br />