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Minnesota Department of Public Safety <br />oglEin r^qT LIQUOR CONTROL DIVISION <br />,�-°� 444 Cedar St. /Suite 100Er.� <br />i�.,c <br />St. Paul, MN 55101 -2156 aka <br />� <br />MIL <br />'� <br />(612)296 -6439 TDD (612)282- 6555 <br />C xig,g <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />(Organization or location limited to 3 pennits in a 12 month period 1I') 2 —(e_ 1) - / 5✓C) 2.. <br />or <br />TYPE OR PRINT INFORMATION Jr- ( q "N- MRW <br />NAME OF ORGANIZATION `:4, c. el `_, , an 9 L I U.b -J-II l . <br />1-`+IFi't CekvNtlt..`S A,brEytrl3 SQbbi-hal (;Iuh, <br />DATE <br />-I1 li <br />ORGANIZED <br />D2. <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />2-11ia g cutknic . A) . . <br />CITY <br />Lid -II•e- CC: v14,ZE c <br />STATE <br />y1/1.' <br />ZIP CODE <br />S.57 /'l <br />NAME OF PERSON MAKING APPLICATION <br />0 Dv') L, aLJivV6t.h <br />BUSINESS PHONE <br />(&i I) .M61 VP t/) <br />HOME. PHONE <br />(bC/) L/go-0ott5 <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />' 7, --2., `3 e e'r) 1'(U c .1(c- iS t Lc UZ, <br />TYPE OF ORGANIZATION <br />f CLUB 0 CHARITABLE 0 RELIGIOUS a OTHER NONPROFPr <br />-O�RGANIZATION OFFICERS NAME <br />DoY) &OW/wan <br />ADDRESS/� �y <br />2'iit 3 f'cLlr 'c. AJ L.ITIII°., Ctt..vt4ik MA; CS 11) <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICERS NAME <br />ADDRESS <br />Location where license will be used. If an outdoor area, describe <br />T ii)vAe(a� Pcur F. 57O1-f- h4,, I <br />H ,e. \ h.!, ti) il {'(7 SS '-r1 Li re 4.1 . <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />N <br />I <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) (,ie. 5 N r'J 1d A tl f I )t te4-.5 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />1 CITY /COUNTY <br />DATE APPROVED <br />CITY FEE AMOUNT <br />LICENSE DATES <br />DATE FEE PAID <br />I <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL. <br />APPROVED LIQUOR CONTROL DIRECTOR <br />1 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 />