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Minnesota Depatuuent 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.MIN.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 />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 />LIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rick Boss <br />BUSINESS PHONE <br />(651) 766 -4029 <br />HOME PHONE <br />(65 l) 490 -3165 <br />DATES LIQUOR WILL BE SOLD <br />o `-C - 27 "' 0�`—P <br />TYPE OF ORGANIZATION <br />CLTJB CHARITABLE RELIGIOUS <br />THER NONPROFIT <br />ORGANIZATION OFFICER'S NAMME <br />Rick Boss <br />ADDRESS <br />72 E. Bryan Street, Little <br />Canada, MN 55117 <br />ORGANIZATION OFFICERS NAME <br />(i.G✓l-I'Z 56 GLi-t>_ <br />ADDRESS <br />25 3D /tl e Pi en 4.- -7, C, C . WI .J S-5-1) 7 <br />ORGANIZATION OFFICERS NAME <br />I1awcy Kep /<r- <br />ADDRESS <br />2-'3 ,..0 c, To, Ch, Lc- w. ,v/ SSG /7 <br />Location license will be used. If an outdoor area, describe <br />2121 Ivt zn .e..,..,7 <br />5 T - :So urn s 5 e-1-0 0 L. c 1-F-A e.2, <br />An c: <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 />OTE: Submit this term to the dry or county 30 days prior ro event. Ponvard 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 (021051 <br />4 <br />