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9Ty.CFNMHfS'� <br />O4o- / <br />V <br />Minnesota Depauiuent 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 />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 />sic K.:jo 11 <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 />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rick Boss <br />BUSINESS PHONE <br />(651) 766 -4029 <br />HOME PHONE <br />(651) 490 -3165 <br />DATES LIQUOR WILL BE SOLD <br />S i PT - i (, 2 ab to <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOUS THER NONPROFIT-) <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />Rick Boss <br />72 E. Bryan Street, Little Canada, MN 55117 <br />ORGANIZATION OFFICERS NAME <br />('l eil Ili J i c IA-0. <br />ADDRESS p <br />2 5-3 0 !1J c glen e,....Y Y� d, G/f& C,ich. gm/ i) /(, <br />ORGANIZATION OFFICER'S NAME <br />N,A,ocy KEF,pcc(n <br />ADDRESS <br />z(i€,s to ;171- L,v L,/f7e c,.,,je. ,ry'� , -5io7 <br />Location license will be used. If an outdoor area, describe <br />1 / (SNEER P }l dl xx L; fide AA n !%'! n S-59 / 7 <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 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 />TK: nubmn tins tm m to the eIry or coon 30 (lays poor to event. Rorward application signed by city and /or county to the address <br />'e. 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 (02/05) <br />3- <br />