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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100L <br />St. Paul, NE 1 55101 -2156 <br />(612)296 -6439 TDD (612)282 -6555 <br />C Ci <br />APPLICATION AND PERMIT <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 <br />TYPE OR PRINT INFORMATION or <br />O / it/4-4-(Q <br />Or ---- 7- r «c/( <br />, <br />DATE ORGANIZED <br />f1 -17 - &z <br />TAMEillt <br />X EXEMPT NUMBER <br />2.9412 <br />NAME OF ORGAMZATIO <br />4 / fri-Le Ccgv /o,d //, _eciecrINA 45soc <br />STREET ADDRESS <br />j /..S 6 Ltff(e (ewictc�<<. �'2 �'1, <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CTY /' / / <br />411 H-ce� CCiota.JU <br />STALE <br />//)/v."- <br />ZIP CODE <br />SS/l-7 <br />NAME /OF PERSON MAKING APPLICATION <br />«�tvt K-e.ev?avt <br />DATE FEE PAID <br />BUSINESS PHONE <br />(las 7 )6/ ce - /-7-o3 <br />HOME PHONE <br />(b,s7)4190- 932‘1 <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />D-4N , Z 2- — 2- Z 3 2-o0S <br />TYPE OF ORGANIZATION <br />0 CLUB ❑ CHARITABLE ❑ RELIGIOUS taOTHER NONPROFIT <br />ORGAMZATJON OFFICERS NAME <br />Ric L4 ,i r__ 3es5 /V <br />ADDRESS <br />7l 0 , 67,-)at n Si CI C -_ <br />ORGANIZATION OFFICER'S NAME <br />Nii/uC7_ e -F Ce(z <br />ADDRESS T <br />Zfg Co5k, Lvl LC- / 7 <br />ORGANIZATION OFFICER'S NAME <br />Ve.4 lie S0GLLOk <br />.mss/ <br />ADDRESS <br />25-3O /'nc%e /wne..l ,Q( LL . .5�-/7 7 <br />Location where license will he nce,t rr' , n„r,1 . <br />,.o <br />ao <br />O / it/4-4-(Q <br />Or ---- 7- r «c/( <br />IIGNATURE 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 />Will the applicant contract for intoxicating liquor sen9ces? If so, give the name and address of the Liquor license providing the service. <br />7) 0 <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) N/./v �t ;�7- OPL IP, c�li � 47 4 ..vo c . 7 3 0/ 0 U O <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />DATE APPROVED <br />CITY FEE AMOUNT <br />LICENSE DATES <br />DATE FEE PAID <br />IIGNATURE 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 />