Laserfiche WebLink
Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, St. Paul MN 55101 -5133 <br />(651) 201 -7507 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 />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />STREET ADDRESS i <br />(, �2 / i( = z�;'77e ' Sl <br />CITY/ , /' / /p, <br />0.4:,l Wife-. <br />STATE <br />411 <br />ZIP CODE <br />:-Ti // <br />/((" <br />NAME OF PERSON MAKING APPLIdATION <br />r <br />/t {/l4./ ��/.t77' �it�i.�!c2-1.‘-• <br />BUSINESS PHONE <br />(65i1) ;' S Y -.3 ...:2,0 <br />HOME PHONE <br />k',5%) '/ ''! —9 /- 7 <br />DATES L I � U O R WILL BE SOLD <br />4 if/ l c:: - 22ry / :-,,, , <br />TYPE OF ORGANIZATION ,— „ii <br />CLUB CHARITABLE (RELIGIOUS) OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />O <(( <br />Ufa • S, CJ/ /G� . �C A 'it " 6. <br />ADDRESS - <br />>'S( /-S./ /c (lr� tixe'(. /0 <br />/ i /1 /e'. (/ ue +e /ict. .//,f/ :.l //'7` <br />ORGANIZATION OFFI ER S NAME <br />// /). <br />ADDRESS / <br />c�(,.a / ,71:1e ..Se.( ( i /5 =( <br />/ / /t e C.': it i - 1 / . <br />ORGANIZATION O,f •ICFR'S NAME <br />ADDRESS <br />Location license will be used. If an outdoor area describe � <br />C/ e{., (./ S t' -4r p/. —(. ,,://L,,,,,. , i i./v - .. "S(%[ <' C /+WSJ a. <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 />F.r - fir ' ,..,..F.()C / /c.,�, ic/ /.t,G.6f i ;ii' C/ /e,,"(r ( /7E'c.,( r: <br />�. >( �. <br />V j <br />`, rS �,,. ;/9 r . ( 7.4, (, : l/ /( / /Ce- /C62.1 ?e6,4 , -,- <br />(7.(24.-/: <br />APPROVAL <br />APPLICATION MUST BE APPROVED I3Y CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY /COUNTY DATE APPROVED <br />CITY FEE AMOUNT LICENSE DATES <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. lithe 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 (12/09) <br />