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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 />'IYrb UIC I'tt7Dt 1 IINrUlUVIA 1 IVIN <br />NAME OF ORGANIZATION <br />L-- 1rrtt- CA,atgtsi4 Pac.RURno,s »W. <br />DATE ORGANIZED <br />,(,,,ra€ ► 9(;), <br />TAX EXEMPT NUMBER <br />2°19 -2_&) <br />STREET ADDRESS <br />515' L-,'rrLE car giii> F} Rei <br />CITY <br />Lerrog cA4664 <br />STATE <br />roil) <br />ZIP CODE <br />s S1 /7 <br />NAME OF PERSON MAKING APPLICATION <br />'Tim o"rtly 'aft (LEm8/ 141 <br />BUSINESS PHONE <br />(Kr) 4,16-7066 <br />HOME PHONE <br />(6si)263 -21 7 <br />DATES 1000R WILT. BE SOLD <br />uG(,I6T 20(2.- <br />TYPE OF ORGANIZATION »c /' PR-0 j , -r <br />CLt1B CHARITABLE REIICIOUS OTHFR ONPR• OFDD) <br />,.i0t�7, <br />ORGANIZATION OFFICER'S NAME <br />Tirno+1,A1 ZRizervi .61:4 K.1 <br />ADDRESS '30Z 1 LEE 0.1 R k-.p (JFi y <br />L^ t tre_t 0/9-rJ A A,9 M..5S) o 9 <br />ORGANIZATION OFFICER'S NAME <br />bE a MDRE Lfin) <br />ADDRESS i O 9 att.,' (,t) 0 01) ,q- t) e <br />Lt Int CA24A'7j 9 M,-) C7S7 / 7 <br />ORGANIZATION OFFICER'S NAME <br />/4er/.1GN ?No,4D &S <br />ADDRESS 3 4 5 3 ;1'R-c -M 1,E. 5 7 <br />0113r-1A /s 1- 1-Ei6-4 TS MA 5S`i27 <br />Location license will be used. If an outdoor area describe SPDO/.} tie Pfriz•l< <br />RC t EL-' Ro/i-b <br />Z,, Tr-t, E C A-INJ et-NA Al ,J S57I 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 />h1D <br />Will the applicant catry•liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />CA P I TDL_ ) Ii D 541'1 N 1-r -j c_o2P- PbLie -4/ 0= 6.) Po/ 3 /y,69,3. <br />APPROVAL <br />APPLICATION MUST IBE APPROVED BY CITY OR <br />ENFORCEMENT <br />CITY /COUNTY <br />COUNTY BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERIC OIt COUNTY OFFICIAL APPROVED DIRECTOWALCOROL AND GAMBLING ENFORCEMENT <br />I/ t ti add •s <br />NO Submit this form to the city or county 30 days prior to event. h onvm•d apphcanon signed by eLLy am or county o tc t ca <br />above, If the application is approved the Alcohol and Gambling Enforcement Division will return this application to he used as the License for the event <br />PS- 09079(05106) <br />2 <br />