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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 W Fax DPS STATE.MNU$G51) 282 -6555 <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />1—J1-ILL cAr1 Ar>$1 gCCRE4T,Dn1 4554. <br />DATE ORGANIZED <br />Cu,U€. 1 °J h <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />616 Ll rTtE k Set <br />NAME OF PERSON MAKING APPLICATION <br />Tnothy ' ftgemg/r Kt <br />DATES IQUOR WILL BE SOLD <br />CITY <br />Lyrae Gf14Rb4 <br />STATE ZIP CODE <br />Mon) S SJJ' 7 <br />ORGANIZATION OFFICER'S NAME <br />Tirrto +kif Zftger't8,rJ5.Ki <br />ORGANIZATION OFFICER'S NAME <br />LDEa 711DRB1A» <br />BUSINESS PHONE <br />(bQ)'/€ -7066 <br />TYPE OF ORGANIZATION ADAM F, <br />1 HOME PHONE <br />0.0)263"2/6 7 <br />o 2. t r•t st C• • • 'CU• t• <br />ADDRESS '3o1 / LE. &t�t1 A�,'fD G✓+`�"L1 <br />1_7 r1c C4AJAfA MA) SS';o9 <br />ADDRESS / O 9 0Lt4 c,0 002) ,4 ti e. <br />Le rrrct cfriv DA 4 5'717 <br />ADDRESS 3ttS3 /Igo:l3E. 57 <br />VFta>r.18tl5 /-f- E/&-14r..< M» 5i. '7 <br />SPooNEg Pt-21< <br />act EL, Ro*a <br />ti 777 ek'Jfr>A MrJ Sol? <br />ORGANIZATION OFFICER'S NAME <br />hI ver L1 Rr -Jo,4 b &S <br />Location license will be used. If an outdoor arca, describe <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address ofthc liquor licensee providing the service. <br />t40 <br />Will the applicant carryliquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />cAPI-rot_ )./4D64'•1,I7JtT.1 c°oeP. pLu rxLPo13147b9. L <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY /COUNTY DATE APPROVED <br />CITY FEE AMOUNT LICENSE DATES <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOWALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this Corm to the city or county 30 days prior to event. Forward application signed by city and /or county to the address <br />above, If tiro application is approved the Atcohoi and Gambling Enforcement Division will return this application to be used as the License for the even <br />PS-09079 (05/06) <br />4 <br />