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Minnesota Department of Public Safety <br />sT LIQUOR CONTROL DIVISION ,' ""°"kh <br />,_ 444 Cedar St. /Suite 100E fir.\ <br />St. Paul, NEN 55101 -2156 4 '��'& <br />mi./ <br />(612)296 -6439 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 tuonth period <br />or <br />TYPE OR PRINT INFORMATION MAW <br />NA.JVIE OF ORGANIZATION <br />.ST. :50 Kw 'S Sa00I <br />DATE ORGANIZED • <br />/ L A � <br />7 TAX EXEMPT NUMBER <br />3 3 ) <br />STREET ADDRESS <br /><9..6 21 to - ��revr�Ia <br />CITY <br />�-)ft-lt& &wd /4 <br />STATE <br />Aff <br />ZIP CODE <br />-057 <br />NAN'IE OF PERSON IV ING APP -EICATION <br />C` fr�ot_- ScH W Rt�T'Z- <br />BUSINES/S P'H/ONEi HOME PHONE <br />(,S() Li$'4-- 305 y ( ) <br />DATES LIQUJOR WILL BE SOLD (I to 4 days) <br />Pt eF \ 30 , aon`1 <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE )&RELIGIOUS ❑ OTHER NONPROFIT <br />ORGANIZATION OFFICERS NAME <br />1�')tllcy /Cc). y )lJN2yV <br />ADppD�RESS <br />.L( S[ �` <br />Y1GG �t'i1 rC >G /� �� /". /� �J �i-ifIPeel� /1/1;(15-.57/ 57 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location where license will be used. If an outdoor area, describe <br />,Sr: ✓Z it i ✓'5 SC /otck,C —' /NOock <br />Ewa ( n'I c v✓/& s-i y s/- <br />A. I ra€ r, Lehr /toA M i 53%i 9 <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) A/0 6- Nt,tik AI Alt 1. i'Jt j - 5L /Yr-nnHl o <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />DATE APPROVED <br />CITY FEE AMOUNT <br />LICENSE DATES <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(13/95) <br />2 <br />