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Minnesota Department <br />oY acszli LIQUOR CONTROL <br />°; 444 Cedar <br />� St. Pant, <br />of Public Safety <br />DIVISION <br />St. /Suite 100L <br />MN 55101 -2156 <br />TDD (612)282 - 6555 <br />AND PERMIT <br />ON -SALE LIQUOR <br />to 3 permits in a 12 month period <br />LICENSE <br />I% I C..I- I.)gC.., <br />/ r�r \\ <br />4 <br />wy 4'' (612)296 -6439 <br />APPLICATION <br />FOR A 1 TO 4 DAY TEMPORARY <br />(Organization or location limited <br />TYPE OR PRINT INFORMATION <br />„ ma. �< <br />or <br />MR I# <br />NAME OF ORGANIZATION 4 / L <br />LiI a (1t4tr,aa Recre4. ia,1 - 550Claben% <br />DATE ORGANIZED <br />J a ny I [‘,z <br />TAX EXEMPT NUMBER <br />-29yd4, <br />STREET ADDRESS <br />s'IS LI ti-k (t- G d .. • Rd. <br />CITY <br />t, /12 4:Rr<:dl, <br />STATE <br />4-1,./ <br />ZIP CODE <br />J i/7 <br />NAME OF PERSON MAKING APPLICATION <br />`2tCAC Doss <br />BUSINESS PHONE <br />(69)7/,6 . elO <br />HOME PHONE <br />(cy) 9 rO -7/45' <br />DATES LIQUOR WILL BE SOLD (I toil days) <br />SEAT- f •tt. Lo 0 .j <br />TYPE OF ORGANIZATION <br />0 CLUB 0 CHARITABLE 0 RELIGIOUS `OTHER NONPROFIT <br />ORGANIZATION,OFFICER'S NAME <br />1CK 15055 <br />ADDRESS SSp7 <br />--7t C i3iLy4g SI. Lt/i /t C,,,..:Ja m' <br />ORGANIZATION OFFICER'S NAME <br />KA,-f -t-e SociAct <br />ADDRESS <br />;Is3o rncmene.,,f2c( Lffd C'.t,,,.. _(... hid 5-s /I7 <br />ORGANIZATION OFFICER'S NAME <br />Pjkwcv KeFFetc,Z <br />ADDRESS <br />2&SS (b54-A L,, Lri%/t Cawe,jek Rid S5 7 /7 <br />Location where license will be used. If an outdoor area, describe <br />f to.t.e.,e -r Pa; 14, L, "tic ear c, a.i, on. rt 3-57/7 <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />I <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) MA). -Jo, AO LA N A en... WRi /-,,)6 455 at; ini DA/ <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 />