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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 (65I) 297 -5259 TTY (65I) 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�ORGANIZATIION <br />LI`Il� IgVIQd4 IIIVIa AM et tAcI i . <br />DATE ORGANIZED <br />fa11711q'g <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />515 e Li —ie. ("(inak 12rA <br />CITY <br />Lt+l le_ C'aneute. <br />STATE <br />MN <br />ZIP CODE <br />55H7 <br />NAME OF PERSON MAKING APPLICATION <br />(i(<5(k1,1 IQelsoh <br />BUSINESS PHONE <br />(c5I) (r61(&-/ 507 <br />HOME PHONE <br />(05() 493 -cfscf/ <br />DATES LIQUOR WILL BE SOLD R'I t�USi Ht (p �L^CC^ <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RFT.TGTOUS <br />OTHER NONPROFIT) <br />ORGANIZATION OFFICER'S NAME <br />51,15a h Neloh , Pesrclent- <br />ADDRESS <br />t .. Labe-1—e— 124, Liitle.Cana e , am) 5s I ( 7 <br />ORGANIZATION OFFICER'S NAME <br />1'ostph G t 0 c ce_ eoi°sI�(e1�t I- <br />ADDRESS <br />X2538 m0flen , L H (t(an&9 mN • 56l 11 <br />ORGANIZATION OFFICER'S NAME <br />I, h�� Bea/L.40ir reasure -- <br />l <br />ADDRESS ' <br />4tl-i e ce Sf-t (cpS L.; ale 6l nada, NU 5553 <br />q <br />Loc tion license will be used If an outdoor area, describe <br />5j000ner ParK , 3so Eli Rd, describe. -(e 0114a24, TAJ 65H7 <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 />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 Sc GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERIC 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 signea 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- 119079 (02/051 <br />2 <br />