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/ //r7 v ( <br />Minnesota Department of Public Safety <br />.:'.$ LIQUOR CONTROL DIVISION � <br />° ..6 444 Cedar St. /Suite 100E r <br />St. Paul, NIN 55 10 1 -21 56 ' f *Sa <br />wF ice (612)296 -6439 TDD (612)282 -6555 MIlh.' <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 or <br />MA1# <br />NAME OF ORGANIZATION <br />L, l 4 (,i.,h t el c, Rec. reJ 1/4,a A-55b C 141704 <br />DATE ORCiANIZ.ED <br />�u n & 1 i oZ <br />TAX EXEMPT NUMBER <br />2• iaZie <br />STREET ADDRESS <br />S' /J' / tfk (,) -4c.x L ' Rd . <br />CITY <br />Lift /e Ctit.,la,; <br />STA 1 h <br />Aid <br />ZIP CODE <br />x .5 1/ 7 <br />NA, OF PER N MAKING APPLICATION <br />(CK OS <br />BUSINESS PHONE <br />431)744 - 11(441 <br />HOME 'HONE <br />(0-/) 9q0 -3/G - <br />DATES-LIQUOR WILL BE SOLD (I to 4 days) <br />CC, 2,0° C <br />TYPE OF ORGANIZATION <br />0 CLUB ❑ CHARITABLE 0 RELIGIOUS Wt OTHER NONPROFIT <br />ORGANIZATIO OFFIC'ER'S NAME <br />1Z Ic K to5S <br />"LION <br />ADDRESS 5 "S /I? <br />-73 C axy4,,i S(. L4/ -f /t C,�..:& - <br />ORGANIZA OFFICER'S NAME <br />KiAtt? sock. <br />ADDRESS <br />. > ,30 mcmene.r <br />f R1. L;i fd C.LM. „Lill() rnA7 <br />ORGANIZATION OFFICERS NAME <br />NA14cv KerPet -ER <br />ADDRESS <br />.28x.5 {`e,5fv. L LiH-1 C,,,..,dA Md SSu7 <br />Location where license will be used. If an outdoor area, describe <br />24. z-i me. htr,ie:,/ 5 r 'tarns scdto ) ~ /4-1'2,1- <br />/ <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) MA). `1 O, A/ 1j jA to Dl fZt,.l,Z1I-,,Q4 45Jec:Af?/onl <br />APPROVAL <br />APPLICATION MIDST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />1 CITY /COUNTY <br />DATE APPROVED <br />LICENSE DATES <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />APPROVED LIQUOR CONTROL DIRECTOR <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />INOTE: 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 />