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Minnesota Depailulent of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMMFNT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55 10 1 -5 133 <br />(65I) 215 -6209 Fax (651) 297 -5259 TTY (651) 282-6555 <br />W4V W.DPS.STA 1 h.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />\(Tre /V 8,q --c <br />NAME OF ORGANIZATION <br />Little Canada Recreation Association <br />DATE ORGANIZED <br />June, 1962 <br />TAX EXEMPT NUMBER <br />29426 <br />STREET ADDRESS <br />515 Little Canada Road <br />CITY <br />Little Canada <br />STATE <br />MN <br />LW CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rick Boss <br />BUSINESS PHONE <br />(651) 766 -4029 <br />HOME PHONE <br />(65D 490 -3165 <br />DATES LIQUOR WILL BE SOLD <br />c 4 i ee 2 00 ie <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOTIS <br />THERNONPROFIT ) <br />ORGANIZATtiON OFFICER'S NAME <br />Rick Boss <br />ADDRESS <br />72 E. Bryan Street, Little <br />Canada, MN 55117 <br />ORGANIZATION OFFICERS NAME <br />Ka-17 c Jo c it <br />ADDRESS <br />(2 5. 30 Mt Me,n z:� y Li. /j// 6,,. („ I'1W 5T5 V/7 <br />ORGANIZATION OFFICER'S NAME <br />/U /FYI) r-9 KEFFet6YL- <br />ADDRESS // /,�{t• <br />),Y)t'i5 Q, 4-c. Lp 2i f/e C.O.ow,.t MN 5 J // 7 <br />Location license will be used. If an outdoor area, describe <br />f7 d 3 !/ ., f,. TT ff$ <br />fo oA -e .c ea A-K. <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 />MN Joint Underwriting Association <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 />NOTE: Submit this term to the eta' or county 30 bays 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 />PS -09079 (02/051 <br />2 <br />