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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100L <br />St. Paul, MN 55101 -2156 <br />(612)296 -6439 TDD (612)282 -6555 <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 <br />or <br />TYPE OR PRINT INFORI fA'fTON tA6 <br />NAMF 11OE ORGANIZATION [ <br />1._/ H62 (or 47q // creoi /0�/I �DC. <br />DATE ORGANIZED <br />I2 - /1 -- <br />TAX EXEtMP I NUMBER <br />29y z(e) <br />STREET ADDRESS <br />5 r .r &, t, Mat (aictc70. 2� <br />CIT <br />�/ Ott c ie,%6� <br />STATE <br />iwf✓ <br />ZIP CODE <br />557/9 <br />NAME OF P, FJiSON MAKING APPLICATION <br />fti -evivl /r?e,�m <br />BUSINESS PHONE <br />( ) <br />HOME PHONE <br />(si) v90 - 9.3 2 f • <br />DATES LIQUOR WILL' BE SOLD (1 to 4 days) <br />S'G 4 , / -7 i- /y •2 0 0'7 <br />TYPE OF ORGANIZATION <br />: CLUB Li CHARITABLE ❑ RELIGIOUS , OTHER NONPROFIT <br />I ORGANIZATION OFFICER'S NAME <br />R/c «:>rd 6josS /1� <br />ADDRESS <br />72- E. ecci4? -7 5 G. C, 5 ^571-2 <br />ORGANIZATION OFFICER'S NAME <br />Lind G. -,�/ <br />ADDRESS <br />zy?6, Cu.4or -e n/ Z,C , 575-i D2 <br />ORGANIZATION OFFICER'S NAME <br />Y=A Fe SOC.(�h <br />ADDRESS <br />ZS3o Mc/��42,�, �Iel (,c, 537/7 <br />Location where license will be, used. -If an outdoor area describe <br />/c� /7 /f6? Cc2t c,d'(°/ rte 4 // <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />NO <br />Will the applicant carry liquor liability insurance? If so, the carrier' s nape and amount of coverage. <br />(NOTE: Insurance is not mandatory) /2r �' ? io -r T' Uri c i^ &vr / Ili ri • ,'4 S{ o �7s02 0'c) O <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />DATE APPROVED <br />LICENSE DATES <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />APPROVED LIQUOR CONTROL DIRECTOR <br />n �: Do not separate these two parts, send both parts to the <br />will be returned as the license. Subunit to the City or County <br />address above and the original signed by this division <br />at least 30 days before the event. <br />PS- 09079(8195) <br />3 <br />