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Minnesota Department of Public Safety <br />SP' <br />a -) sT� Lily CU!v I1tcUL IIIVISIU N ice <br />444 Cedar St. /Suite 100E j�� <br />` St Paul, tih 55101-2156 i <br />(612)296r-648-9- TDD (6-1 -2)282 -6555 <br />�CF un�E,. <br />Ij�IRy§. .Y. L' / Y' f) <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 n -5 / — / ? �_,,c /c /-y <br />TYPE OR PRINT INFORMATION or <br />NANIE OF ORGANIZATION <br />L-iiile LatrI d /L& L 4Ia',iiVII1l U5 c <br />DATE ORGANIZED <br />12/17 /73 <br />TAX EXEMPT NUMBER <br />STREET ADDRESS / <br />5l5 i= Litflr Cnrlactc. K :cQ <br />CITY <br />14( (i 7 <br />�--� � e= CP,afl'�L. <br />STALL <br />/11111 <br />ZIP CODE <br />5il("7 <br />NAIvtE OF PERSON MAKING APPLICATION <br />,..f30 SCmmi I/ <br />BUSINESS PHONE <br />(6,5O& /,7 /407 <br />HOME PHONE <br />(1/)el=?3 �If/ <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />A11,141.4.51' 2,3 E4 Zct Z <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE 0 RELIGIOUS ,&j OTFER NONPROFIT <br />ORGI\MZATION OFFICERS S NAME <br />:51,.15(i41 AJ /`�.vi /4'esicir)0— <br />ADDRESS <br />76,2 _ L„b_c „• /e t . [_iIflr (7p.,L,cla tiMi 551/7 <br />ORGANIZATION OFFICERS NAME <br />l_i:=(L O);YOI 11iLe.. VG"�/,1 }i— <br />ADDRESS <br />-Kelp 1111i I^.Clr.'.I- C)G'. KCh L� // A (//',.J,.; %M/() 56/7117 <br />RGANIZATION OFFICERS NAME <br />) ' bya . Wit',-) n AL , .5.01 -,N 17 rz -1 <br />ADDRESS <br />i l�l �G� „� { <br />/ ' <br />� 1 6 � <br />(/ Lil (7I ,,,Ir G�7ry /l 7 <br />.3.� <br />Location where tice�yygse will be used. If ail outdoor area, dcscrrbe�/��, / /� <br />7r?C ortkr l�lr -550 r_. /,Kf, 2[S( LW- E i'lin1,(:(tl 7%XV <br />I <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />Ai (, <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) Ail. 11 ;1e - (7c T ot,1 F 1,111(1e-() r' i ' fjOdia 7Z <br />cl) /l>l /L <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />:ITY FEE AMOUNT <br />DATE FEE PAID <br />IGNATURE CITY CLERK OR COUNTY OFFICIAL <br />DATE APPROVED <br />LICENSE DATES <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 />