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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite I00L <br />St. Paul, NEN 55101-2156 <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 month period <br />TYPE OR PRINT INk ORMATION <br />NAME OF ORGANIZATION <br />Z, file E l �n i a4 F � e <br />STREETADDRESS S75 z-i f`i'r -c <br />-u C /}ni. pri, A- '2-n <br />NAME F PERSON MAKING APPLICATION <br />CL-K 3C SS <br />0n <br />4450 <br />DATE': rr TInn "ITT r RE SOLD t]ito 4 days) <br />z r o <br />ORGANIZATION OFFICERS NAME <br />'Rick 73655 <br />Cr <br />MEW <br />DATE ORGANIZED TAX EXEMPT NUMBER <br />�uv1e I (i4^a a <<�aG <br />CITY STALE 02 <br />CODE <br />Li i 1� (� �� %%4 /ti S S Il 7 <br />BUSINESS PHONE HOME PHONE <br />(lsl) 7(», - 4-1 c2cl (6,st) '190 -3 /Gs <br />TYPE OF ORGANIZATION <br />C CLUB 0 CHARITABLE ❑ RELIGIOUS OTHER NONPROFIT <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME ADDRESS <br />�rctt`E. Soc—H- a_ . ;2. C.3b At_ 1 g✓t % ! L, /E =_.. cda /lt, 5. I7 <br />ORGANIZATION OFFICERS NAME ADDRESS <br />N/hJG/ Ko-ff--/< r Afl 5 CE <br />Location where license will be used. If an outdoor area, describe <br />fiCTnce.r fc r K L!.I11c r 4 1a7n <br />L_r7 <br />4 bPk 4„. ci /1t C 57f 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 />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) 711N :Ft „ { ((a .e r icr j i! /}S; ac ._ F at. <br />r <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />CITY FEE AMOUNT <br />DATE FEE PA rD <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />DATE APPROVED <br />LICENSE DATES <br />APPROVED LIQUOR CONTROL DIRECTOR <br />DOTE: 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 />