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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Patti 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 I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />Li i-1-1-9 (AMC' 61 Rec-A /fss ©G_ <br />DATE ORGANIZED <br />(1-11 -oz_ <br />TAX EXEMPT NUMBER <br />29LI zip <br />STREET ADDRESS <br />615 E Lt -E1 (outdo ad <br />CITY <br />til<4(Q Um/14 <br />STATE <br />v4Al <br />HOME <br />(61)'t9o- <br />ZIP CODE <br />5s117 <br />PHONE <br />-9.32y <br />NAME OF PERSON MAKING APPLICATION <br />KW1 A Vf4aln <br />BUSINESS PHONE <br />(bl2)zai -2tS <br />DATES LIQUOR WILL BE SOLD <br />:Vol A, Z. 0—Z1 1007 <br />TYPE OF ORGANIZATION <br />B H k:L R <br />ADDRESS <br />12 G. 67aP) S7. LC-- <br />.ET HER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />RLI✓[ara F, 6055 .7-iC <br />vki✓ S'S/17 <br />ORGANIZATION OFFICER'S NAME <br />AI kNG `Y Vp cif b r- <br />ADDRESS <br />zw- cost r t to 1,c( , s--6-7/ 7 <br />ORGANIZATION OFFICERS NAME <br />Volpe, S 6 clA to <br />ADDRESS <br />2�3O N1 cc/lean sT, 'Lit ni SSA /7 <br />Location license will be used. If an outdoor area, describe, <br />Ot- Lin-Le C <br />f emadi,; Firs /,4 (-L <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />! V o <br />Will the applicant carry liquor liabilq insurance? If so, please provide the carrier's name and amount of coverage. <br />vim/ 5duh -r- u✓7de6,vnli✓ y FidsQc , '7 SO 000 <br />J ; <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 CLERIC OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />VOTE• ' b ' <br />• Sn mrt tlus 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 tor the event <br />PS -09079 (02/05) <br />