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Minnesota Department <br />otii^s� , LIQUOR CONTROL <br />444 Cedar <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 />t , <br />t Si.- <br />'a ) <br />U St Paul, <br />(612)296 -6439 <br />rasa <br />APPLICATION <br />FOR A 1 TO 4 DAY TEMVIPORARY <br />(Organization or location limited <br />TYPE OR PRINT INFORMATION <br />��' <br />Or <br />NAME OF ORGANIZATION <br />.H <br />// / i le C"641c2.4 REL. gear / o A: A55 cc (Arm, <br />DATE ORGANIZED <br />ZP'» c' ) 910.22. <br />TAX EXEMPT NUMBER <br />02c14 2 (v <br />STREET ADDRESS <br />S-/ 5- L /rr.0 C4Nh*4 • RD. <br />CITY <br />4ir1'lc- eo,,.,,LL <br />STATE <br />/h^/ <br />ZIP CODE <br />554-7 <br />NAME OF PERSON MAKING APPLICATION <br />'Rtu( lks$ <br />BUSINESS PHONE <br />t5l) 7(v& - `lo) -ct <br />HOME PHONE <br />(As /) Vic --3iIPs <br />DATES LIQUOR WILL BE SOLD (I to 4 days) <br />4U(,• L 3 ooil <br />TYPE OF ORGANIZATION <br />n CLUB 0 CHARITABLE 0 RELIGIOUS ,k' OTHER NONPROFIT <br />ADDRESS <br />53D A1 »wi er'y, L,rr1.EGfNI1v,4 iYIJ 5 -5717 <br />ORGANIZATION OFFICER'S NAME <br />Kare Sac MA <br />ORGANIZATION OFFICER'S NAME <br />/VAN Ly JCC FFLC/L <br />ADDRESS <br />x8B3 GojrA LA&E Girlie en4ADf P1/i, 5-37/7 <br />ORGANIZATION OFFICERS NAME <br />R.14-K.- 3c5,' <br />ADDRESS ' <br />'72 C. B4-'y'AN Sr- L,TTLC (4y✓1w» /YIN,.S 47 <br />Location where license will be used. If an outdoor area, describe <br />C Poo a/6-tL ?/t-s -K L/rrt•r_ C/FMM?1- yljV 537/7 <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) )PIN. T„ ;,s/ r JA/062 wza r »Q ,4 55 CG,Atr/a.d <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY Z /hi /C (//),}449, <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 />