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Minnesota Department of Public Safety <br />aF- ---.. LIQUOR CONTROL DIVISION <br />a X01 <br />; 444 Cedar St. /Suite �'/r� � <br />,100E <br />St. Paul, MN 55101 -2156 Altia <br />syo (612)296 -6439 TDD (612)282 -6555 -'' /, <br />APPLICATION AND PERMMIT <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, i4/ - / 3t /4i7 <br />TYPE OR PRINT INFORMATION or <br />IIAF• <br />NAME OF ORGANIZATION <br />Li ftje, Ca Afl'ilL ((Nl Otuj $ td e . <br />DATE ORGANIZED <br />i -11-i /.Q <br />TAX EXEMPT NUMBER <br />STRIETADDRESS <br />3v5 E Li4le <br />�� <br />Ft (avt,4�L <br />CITY <br />Li Iff Ukt4 ..c <br />STATE <br />in /V <br />ZIP CODE <br />'661( 7 <br />NAME OF PERSON MAKING APPLICATION <br />5Clai,. N)e -hw,ryL_ <br />BUSINESS PHONE <br />(IS) 06, -(P6o7 <br />HOME PI-IONE <br />(661) & $. -ill <br />I1 [Es LIQUOR WILL 13E SOLD (I to 4 days) <br />4,155 (� 7 4 >7 0300(4 <br />TYPE OF ORGANIZATION <br />n_ CLUB 0 CHARITABLE 0 RELIGIOUS AO114ER NONPROFIT <br />ORGANIZATIOt�N � OFFICER NAM <br />14 an T> �V-re ( iV rp51davit <br />ADDRESS <br />;Z5iQ CAre L <br />q <br />Dr, Itit{'teF S6,t(LckttPlaid ' jjo <br />O GA IZATION OFFICERS NAi <br />Sin n w ki(e- h? ffSi i ;� 1.- <br />ADDRESS, <br />a M <br />1,96/ me 74-ve . I_i f / ((wk., m) C../511 7 <br />ORGANIZATION OFFICER'S NAME <br />knne ce..chrn/3nn I Oa%Ke,ir <br />t.On ➢limn whew Gnrncp.�ilI tiA ., �A TF .... _ ..,__.._ <br />ADDRESS <br />755 /1('_C! der &v wet-, l Iff(e 840,4 »//AJ g5 7 <br />6roemer Park- , "5!70 l; e) <br />MU 55( 7 <br />Will the applicant contract Cot intodicatuig liquor services? If so, give the name and address of the Liquor license providing the service. <br />�0 <br />Will the applicant cagy liquor liability insurance'? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurauce is not mandatory) IV( i 111 Yl i %:otec_ T� • c'y "tJ' I ft o-'t,f ti55 `t 4...:") 100 /l 0 <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 PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL" <br />DATE APPROVED <br />LICENSE DATES <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(3/95) <br />