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Minnesota Department of Public Safety <br />voF'cr-1s;i: LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100E <br />St. Paul, MN 55101-2156 <br />(612)296 -6439 TDD (612)282-6555 <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR <br />(Organization or location limited to 3 permits in a 12 month period# <br />TYPE OR PRINT INFORMATION <br />LICENSE <br />r, <br />b AP- <br />Liiik <br />Ia. <br />or <br />MR <br />NAME OF ORGANIZATION <br />Little Canada Recreation Association <br />DATE ORGANIZED <br />June, 1962 <br />TAX EXEMPT NUMBER <br />29426 <br />STREET ADDRESS <br />515 Little Canada Road . <br />CITY <br />Little Canada <br />STATE <br />MN <br />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rick Boss <br />BUSINESS PHONE <br />( ) <br />HOME PHONE <br />(651) 490 -3165 <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />August 3 and 4, 2002 <br />TYPE OF ORGANIZATION <br />0 CLUB ❑ CHARITABLE 0 RELIGIOUS )j OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />Rick Boss <br />ADDRESS <br />72 E. Bryan Street, Little Canada, MN 55117 <br />ORGANIZATION OFFICER'S NAME <br />Katie Soucha <br />ADDRESS <br />2530 McMenemy Street, Little Canada, MN 55117 <br />ORGANIZATION OFFICER'S NAME <br />Linda Fahey <br />ADDRESS <br />2926 LaBore Road, Little Canada, MN 55109 <br />Location where license will be used. If an outdoor area, describe <br />Spooner Park, Little Canada, MN 55117 <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) MN Joint Underwriting Association <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY Little Canada <br />DATE APPROVED <br />LICENSE DATES <br />CITY FEE AMOUNT Waived <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 />2 <br />