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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 />1 Y lit UIS VIK INt UNI• twin 1 ivw <br />NAME OF ORGANIZATION <br />I—Int- - CAr1RAii plEcgEmpai1 4S5e) <br />DATE ORGANIZED <br />,JUeSf I g(n- <br />'FAX EXEMPT NUMBER <br />°) 9,2_6, <br />STREET ADDRESS <br />61C"' 4.1 rrt.a CA-A.1/ib H f2cf <br />C1TY <br />Lima crnmD } <br />STATE <br />/„ r) <br />I LIP CODE <br />g- Se / / i <br />NAME OF PERSON MAKING APPLICATION <br />li6'' our kV ZerA ern &,3‘ , <br />BUSINESS PHONE <br />(b))gg6 -7066 <br />HOME PI-tONE <br />(6.1)2.43 - -2.967 <br />DATES LIQUOR IL EE SOW, <br />L " o 4"S 2 b LO )2 <br />TYPE OF ORGANIZATION »OA3 PRcr <br />GI AIR CHARITABLE' NIL OIO(1S <br />F, r <br />OTHER ONPI I' <br />t <br />ORGANIZATION OFFICER'S NAME <br />- nr-Io+11 ZfRi=r"1.84Ai5 ?■ <br />ADDRESS '302,1 LEEu/ AR- .h 4,,fri-% <br />L..tr~t & C4rlAAA m4 S-s- 1D9 <br />ORGANIZATION OFFICER'S NAME <br />IEa 7r1DRl <br />ADDRESS / 09 <br />Lt rrct C4i'J4Z,9 <br />Q(U 6,0 D on <br />n* <br />, -gRcA2 <br />116-#4'rS <br />,4 0 E. <br />SS// 7 <br />€ .C7 <br />ORGANIZATION OFFICERS NAME <br />t Jv -rlcy ?g o6) <br />ADDRESS 3453 <br />VPr.hi-1,4/.5 <br />MA 5127 <br />Location license will be used. If an outdoor area, describe ST' <br />Ets\),I G6- -Li 1 t4a0L <br />T D ki T <br />L ,74 n1c 4etJ 6» y ST: <br />L.trn,E CA -.JAM Mr3 CCU 7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />/A6 <br />Will the applicant carry liquor liability insurance? if so, please provide the carrier's name and amount of coverage. <br />CA P1 TbL ) hi DC.-vir! l 7-4 co P. PDLrul rt C:f0 /3141b9�. <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERIC OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward appltcatI n stgncd by city and(or county to the adds ess <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the evens <br />PS.09079(05M06) <br />6 <br />