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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 (651) 297.5259 TTY (651) 2826555 <br />W W W.DPS,STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INPUKMA t IV w <br />NAME OF ORGANIZATION <br />),ITTI.t- CFi,16th . R &LgEAT)D4 455e. <br />DATE ORGANIZED <br />cL3,nI£ Igo_ <br />TAX EXEMPT NUMBER <br />p.-°)(f z_eo <br />STREET ADDRESS <br />515' Lt r•rcE ChiNIA6 I Rd <br />CITY <br />Lunt t,4 4 <br />STATE <br />M 4 <br />ZIP CODE <br />s S I I `7 <br />NAME OF PERSON MAKING APPLICATION <br />T # oth1 Zerge -r $l'�! <br />BUSINESS PRONE <br />(66-0 zi -7o 66 <br />HOME E <br />PR 29 <br />DATES LIQUOR 1L BE S01.D f <br />OL tO (6,""s de p 2-014- <br />TYPE OP ORGANIZATION »OP <br />CLUB CHARITAB1 F RM. <br />Pio,1 T <br />GIOUS OTHER agiEgir <br />R teb W M-9 <br />ic1 M 4 SS109 <br />! <br />ORGANIZATION OFFICER'S NAME <br />i o n 1)+11 Zii- f i e n LnAl i g-! <br />ADDRESS So 1 / <br />4.. , rre E <br />LEEt✓t1 <br />C4/-1/ <br />ORGANIZATION OFFICER'S NAME <br />IDES mDoEGA.•) <br />ADDRESS / O 9 et.0 0000 (4 06 <br />Li 7-7 cE c (4-Zrg 49 sc1'7 <br />ORGANIZATION OFFICER'S NAME <br />j,(A -PNl�y RP forg be <br />ADDRESS 3 i4 53 j� Zci1-bE 7 <br />)&v- i:9'IS N-EIG -µ'FS MA 5S) ;7 <br />Location license will be used. Iran outdoor area, describe Sr .Jb t4 7146, Eij44 &6Z /s. � c ^hvDL <br />;4.24 me 6,.J &r✓ty Sr- <br />i__ 1 Tr-LE. CAiJr4tA- 14 i SS7/7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />P30 <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />CA P i Tb L ) hi D E a r ✓ l ;1/4-)17-Al coals. PPLl c y r CPO/ 3 l 4 b 9 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR <br />ENFORCEMENT <br />CITY /COUNTY <br />COUNTY BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />I! t to the address <br />NOTE: Submit Ibis form to the city or county 30 days prior to evmtt, forward apphcatton signed by city ant or coon y <br />above. If the application is approved the Alcohol end Gambling Enforcement Division will return dds application to be used as the License for the event <br />P5,09079(0906) <br />8 <br />