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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 Fax DPS STATE MN USES 1) 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 />L,Trc-E- CAPJ1RnItit ",ec.R>+AiripAl <br />STREET ADDRESS <br />515 L.1 rTLE c/tr■lh» Fl- Red. <br />NAME OF PERSON MAKING APPLICATION <br />T^'\otH ZFt(tE.m <br />DATES Lligt vicorigivioacarit iC 2012_ <br />ORGANIZATION OFFICER'S NAME <br />ORGANIZATION OFFICER'S NAME <br />DE mDIer4 <br />ORGANIZATION OFFICER'S NAME <br />1•ff�r+G�j J <br />'15i0/4 *06.5 <br />Location license Will be used. If an outdoor area describe <br />DATE ORGANIZED <br />31,li•1E I 94:1- <br />CITY STATE <br />Lerrt4 Mme' »4 M on) <br />TAX EXEMPT NUMBER <br />ZIP CODE <br />BUSINESS PHONE HOME PHONE <br />(w) 1 imp —7066 (64) 26 %967 <br />TYPE OF ORGANIZATION laotiii per' f'D <br />CLUB CHARITAIiI F RFI 1GIQ,US OTHER ONPROF <br />ADDRESS '73o a! LE2t.JA&Z LJ/4(1 <br />/_, r7' t C4 -r-»6 AA m.^} SIC 109 <br />ADDRESS / D 9 (34(4 (4O0L) ,4 (Je <br />Le rrti C,Fr1(4 >A M0,-1 55117 <br />ADDRESS 3453 it 2r_/•tre S7 <br />013)r1 ,4i5 1--e16 -14-'rS ,v171 5S) .27 <br />PI ©r3 ea. P449--4( <br />2-9 CO (', 1.1- TC2.v►uc_ 20 At <br />1..--1 rr lt M r1 5S7/7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />/• ID <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage, <br />CA P I Tt>L J N 1 64-yi /J j-r1 CORP. PpUcg o C,001314'bg„. <br />APPROVAL <br />APPLICATION MUST BC 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 CLERIC OR COUNTY OPEICtAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address <br />above, If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event <br />PS09079 (05/06) <br />6 <br />