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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100L <br />St. Paul, iYN 55101 -2156 <br />(612)296 -M39 TDD (612)282-6555 <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />(Organization or location limited to 3 permits in a 12 month period <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />i °(? 20“70 R-e c repro 0 <br />l sscc <br />STREFADDRESS /SISP L -Re �wta�q <br />NAME Of PERSON MAKING APPLICATION <br />l PWV1 ,<Q2icv <br />DATES LIQUOR WILL BE SOLD (1 to 4 d ys) <br />G✓r, Z 1- 2z 200 <br />ORGAt�7ZATION OFFICERS NAME <br />,%c ur c , /3os I <br />ORGANZATION OFFICE WE <br />DATE ORGANIZED <br />CITY � <br />/_iFth CG 46 /cj <br />or <br />MR • <br />TAX EXEMPT NUMBER <br />29g 2 Ca <br />STAfh ZIP CODE <br />4'1 SS!/ <br />BUSINESS PHONE HOME PHONE <br />(X ) 6 /2 -2(Fl- I US (Y5f) y90 - 9 3 2- '( <br />TYPE OF ORGANIZATION <br />❑ CLUB 0 CHARITABLE 0 RELIGIOUS KOTHER NONPROFIT <br />ADDRESS <br />72 Eieiyon 57 LC 53/(`7 <br />ADDRESS <br />Z& cos(z, if/ LC 537/ -7 <br />ORGANIZATIO OFFICER'S NAivIE ADDRESS <br />Ke/ /-e -loch q 2-536 /47641edPi. t i <br />_ ocation where license will be ed. If an outdoor area, describe <br />�� ✓_) (71-/- raecr A , 2P l0 /( <br />LC <br />Vill the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not maudatorv)�/,,� ;j o iW— t U�,,�w �i % <br />APPROVAL <br />APPLICATION MUST BE .APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />ITY /COUNTY DATE APPROVED <br />ITY FEE AMOUNT LICENSE DATES <br />nATE FEE PAID <br />' ()NATURE CITY CLERK OR COUNTY OFFICIAL <br />APPROVED LIQUOR CONTROL DIRECTOR <br />NOTE: Do not separate these two pans. send both parrs ro the address above and the original signed by this division <br />will be returned as the license. Submit to the Citv or County it least 30 days before the event. <br />13S- 09079i8 /95l <br />