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Minnesota Department of Public Safety <br />„aFe-1L 1r LIQUOR CONTROL DIVISION <br />,% 444 Cedar St. /Suite 100L <br />' 77 ° St. Paul, MN 55101 -2156 <br />r7 (612)296 -6439 TDD (612)282 -6555 <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />/ <br />(Organization or location limited to 3 permits in a 12 month peiod "I <br />/ -1 <br />+ <br />MIII.�' <br />?)4(v -o -7 <br />TYPE OR PRINT INFORMATION M <br />OF ORGANIZATION <br />Litile.Gana.44 (aanot,d) a DLt�S _try <br />DATE ORGANIZED . <br />14)7/1973 <br />TAX EXEMPT NUMBER <br />ST ET ADDRESS <br />15 6 L� I-le_ Cana I2.�� <br />CITY . <br />LrtEl -r<. rallAii <br />STALE <br />ZIP CODE <br />55/17 <br />NA4�EE OF PERSON MAKING APPLICATION <br />u vi IUP I n <br />BUSINESS.PHONE tHOME PHONE <br />(6A) t1162-&26-7 I(AA6I) 4:1(-2 5 -46 / <br />D, • TES LIQUOR WILL :E SOLD (1 to 4 days) <br />t.(.:Je 5. 02,C.)"i5 <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE ❑ RELIGIOUS ,dyj OTHER NONPROFIT <br />ORGA ZATION OFFICER', NAB <br />To • ci -re(I , l�?`I,2�� <br />� <br />ADDRESS <br />S1k-i <br />,R3 c((rcf~�: tol,ir_'i6k,,,. YYIN .5g/( <br />QRGANi2ATION OFFICER'S NAME <br />G' • 6 i;'1 're - <br />ADDRESS <br />� z,f)- �Sf- '(zr��0w <br />t ;r'-n-- -o s= x-.51. <br />-0,'c A. / &S (.t'iLIP MA) 66/( <br />ORGANZZ�TIONOFFICER'SNANE • <br />"1111 �Jee -il Ma ii I`1 r 1 YPG1 Si/i it 'i- <br />ADDRESS /� "' <br />1 2A Kp lip-Ali- P4r1(b ti-iNt all /eit. 1214/ <br />., ocation where license will be used. If an outdoor are describe r <br />,540Coner Pale 5o I 1; '- L[-11 le &ma, ri - 55117 <br />1 <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />1\;t' <br />Jill the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not m a n d a t o r y _ <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMII'1INGTO LIQUOR CONTROL <br />ITY /COUNTY DATE APPROVED <br />- ITY FEE AMOUNT <br />DATE PEE PAID <br />':NATURE CITY CLERK OR COUNTY OFFICIAL <br />LICENSE DATES <br />APPROVED LIQUOR CONTROL DIRECTOR <br />NOTE: Do not separate these two parts. 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- 091179(8/95) <br />