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• <br />Minnesota Department of Public Safety <br />y` r T� LIQUOR CONTROL DIVISION <br />u„ 444 Cedar St. /Suite 100L <br />Z -; St. Paul, NN 55101-2156 <br />(612)296 -6439 TDD (612)282 -6555 <br />a8 <br />L, t./ <br />APPLICATION AND PERrMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR <br />(Organization or location limited to 3 permits in a 12 month petiodS <br />TYPE OR PRINT INFORMA ION <br />`I <br />LICENSE <br />/1 /• /CN V/7Le-._ <br />tir <br />A #a <br />772> <br />or <br />lARI# <br />NAME /� /OF ORGANIZATION / L <br />Gll7lfa 4 /I.,Aa.(1cl- Rec('Pa1io�9 %55bCiahod <br />DATE ORGANIZED <br />lk, n -z, Ii6, 2 <br />TAX EXEMPT NUMBER <br />2gVd4 <br />STREET ADDR/E�.SSSD /. P <br />5,5 t / (/k l0-4 d ' Rd. <br />CITY <br />L { <br />4,/ le €t -k,,h <br />STATE <br />/n /1 <br />ZIP CODE <br />J3-7/7 <br />NAME OF PERSON MAKINCG APPLICATION <br />BUSINESS PHONE <br />(657)744 - '(oad <br />HOME PHONE <br />(G)-7) 490 -3145 <br />DATES LIQFJOR WILL BE SOLD (1 to 4 days) <br />Sert 6,4-'1 a- irk <br />TYPE OF ORGANIZATION <br />a CLUB 0 CHARITABLE ❑ RELIGIOUS VOTHER NONPROFIT <br />OR0 MZ_ATIOty,OFFICER'S NAME <br />2isk Do 55 <br />ADDRESS <br />7: e- (t> -,J . 44r6,...:.,A M» 6-5 1I7 <br />ORGANIZATION OFFICER'S NAME <br />Ktif/t' 5oclhcl. <br />ADDRESS <br />,i 7 30 mcm'19ene.> RI L ;ff6 ea,.. At kid 5-57/7 <br />ORGANIZA'T'ION OF'FICER'S NAME <br />N kNCY K e FPO eit <br />f <br />ADDRESS tt <br />.+Z 385 -c{ (e5 L LI [,t e ,-,1,. m.,r 5-5-7/ 7 <br />Location where License will be used. If an outdoor area, describe <br />Sfoo,n er• ecYkK LI M'h' e, ,,Arc, lM.n SS717 <br />Will 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 mandatory) ill /U. To, /Jt a ND -0 ILWit i %/,JC- 455 0 c / /Et/ on/ <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />DATE APPROVED <br />LICENSE DATES <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <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- 09079(8/95) <br />