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Minnesota Department of Public Safety <br />uP. <br />ee.sr,,, :. LIQUOR CONTROL DIVISION =te r <br />- .1,, '417,, 444 Cedar St. /Suite 100E a'' <br />St. Paul, N N- 55101 -2156 a A i <br />�°— 6r (612)296 -6439 TDD (612)282 -6555 <br />L. &g <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMVIPORARY ON -SALE LIQUOR LICENSE <br />(Organization or Location limited to 3 permits in a 12 month periods# <br />TYPE OR PRINT INFORMATION rte( T O $ 9 1 - 0 9 N I I S? MS <br />FG}#_ <br />NAME OF ORGANIZATION I <br />5-ti :rein. Th. Govanye�isT Cehoa I <br />DATE ORGANIZED . <br />TAX EXIT\ PT NUMBER <br />- 5 32333o <br />STREET ADDRESS <br />2(0 2 1 Mc Mc en.y Rai. <br />CITY <br />Li 4- 4-It_ Ca,,.j&— <br />STA I E <br />1'VI.JUi <br />ZIP CODE <br />55i/'7 <br />NAME OF PERSON MAKING APPLICATION <br />SC-\,o0) —) <br />f <br />BUSINESS PHONE <br />((sl) y8HI- 3038 <br />HOME PHONE <br />( ) <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />ApRt 1 as, 2 00(0 <br />TYPE OF ORGANIZATION <br />0 CLUB 0 CHARITABLE [ RELIGIOUS 0 OTHER NONPROFIT <br />ORGANIZATION OFFICERS NAME (Gst- y,L - 1 <br />Mar'1 Ka1 12_awaN) \.kvz cm 30 ) <br />ADDRESS <br />3ty 5-4a -ie eck :b2, Piaii10MeJ in N, Ss'/ s` <br />ORGANIZATION OFFICERS NAME <br />St 1too.Q <br />ADDRESS <br />yl'wa k Vv., 6 s i - )88 • 302;2 0 <br />____._ . <br />OFFICE -R S NAfVLE <br />Location where license will be used. Ii' an outdoor area, describe <br />TNSidie +Lc Sclwot ci••yyvr a o (3&4 &cc;ua S ecicP <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />NO <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />2ITY /COUNTY <br />:ITY FEE AMOIJNT <br />DATE FEE PAID <br />IGNATURE CITY CLERK OR COUNTY OFFICIAL <br />DATE APPROVED <br />LICENSE DATES <br />APPROVED' LIQUOR CONTROL DIRECTOR <br />:NOTE: Do not separate these two parrs. send both parts to the address above and the original signed by this division <br />will be returned as the license. Submit to the City or County at least 30 days before the event. <br />PS -' 9079(S!9 ) <br />