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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St, Paul MN 55101 -5133 <br />(651) 201.7507 Fax (651) 297 -5259 TTY (651) 282 -6555 <br />W W W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE UK PKIN 1 IN'UtcMH 1 IVly <br />NAME OP ORGANIZATION <br />L-1T7-teL C E- I74h19 jEC.ReAT)Dn1 455O. <br />DATE ORGANIZED <br />314.t4C 1 ' 9 4 , - ) . <br />TAX EXEMPT NUMBER <br />ac) tf Z(cr <br />STREET ADDRESS <br />816 L/ rrci cfnJAb Pr .get <br />CITY <br />LtrnL CR,4664 <br />STATE <br />M» <br />ZIP CODE <br />S S I I '7 <br />NAME OP PERSON MAKING APPLICATION <br />Tinot R'J aFtR4Jm 6/+3K -! <br />BUSINESS PHONE <br />(bsr) 4810 °70617 <br />HOME PH NE � <br />DATES LI•0 mugs <br />yy1 a 2. <br />TYPE OF ORGANIZATION ACV'S PP-0 <br />t •• t a t t • <br />rr <br />•' ' t 05RINZ•tlYI <br />.s' <br />ORGANIZATION OFFICER'S NAME <br />-norm-Hi ZAFZEr1,einIJ ( <br />ADDRESS "3O1 / L_EEt tJ R iab 44.1 01-9 <br />j, rtL-E. C74-,l,1 ,al /Y)4 CS109 <br />ORGANIZATION OFFICER'S NAME <br />DE dip RE? la <br />ADDRESS / 0 9 81.44 (4) 0 b2) /• ) E. <br />Lt 77-4.1 c4 14>9 4 5,5/17 <br />ORGANIZATION OFFICER'S NAME <br />/•i 7NIc_y ii0,4i >6S <br />ADDRESS 3 t.# S 3 �(LC_ i-h!se_ 'S 7 <br />VA'D/4a15/}�14616-14 Mr1 5S7 27 <br />/Tj. <br />Location license will be used. If an outdoor area describe Pi DID — t eT" T <br />191 CO C.41JT.VIU <br />e (22M.t <br />L `t i tt Grit tvbh- M -I 5S117 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />' b <br />W iUI the applicant carry liquor liability insurance? If so, please provide the carrier's naive and amount of coverage. <br />CA P 1 TUL- 1 N b IM-7-Li cola!). Pobat LPal3 <br />l z{Pa9, <br />. <br />APPROVAL <br />APPLICATION MUST 13E APPROVED BY CITY OR <br />ENFORCEMENT <br />CITY /COUNTY <br />COUNTY BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL Sc GAMBLING <br />CITY PEE AMOUNT <br />T <br />DATE FEE PAID <br />SIGNATURE CITY CLERK Olt COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />1! t t 16 dtl ress <br />NOTE: Submit this form to the city or county 30 days prior to event. Forwncd application signed by esty aut or coon y o o a <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for ibe event <br />PS- 09079 (05/06) <br />4 <br />