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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite IDOL <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 4) — 134- 4447 <br />TYPE OR PRINT INFORMATION 1, <br />NAME OF ORGANIZATION <br />:....r ,•,'', <br />DA =al PA li <br />12. <br />TAX XEMPT NUMBER <br />STREET ADDRESS <br />t . .,, ... <br />CITY <br />l i ea _ <br />STA 1 ZIP CODE <br />AIM 5511 <br />NAME OF'N�SOON MAKING PLICATION <br />r I . HOME PHONE <br />D TES LI1lJOR WILL BE SOI,D (1 to 4 days) <br />i/. • .• •• <br />TYPE OF ORGANIZA ION <br />❑ CLUB 0 CHARITABLE ❑ RELIGIOUS ? OTHER NONPROFIT <br />ORO • Z.ATI N /FFI ER' AME <br />41 reS( <br />ADDRESS <br />% <br />GANIZATION OFFIC WS NAIy�MEn� <br />' <br />ADDRESS <br />30Z /1 iJ <br />4 •u. L,. I <br />p <br />` •1 , at /.-.F_ J/! 5 <br />J n .' :w c ' lies, <br />ORGA ATIO OFFICER'S NAME <br />Lo <br />,al a ,. /✓ .�i'.; % <br />1 �•„ , <br />-' / t' <br />Location where teens vill be used. If outdoor area, describe <br />.Spooner {start_ 350 E Its eit LA EE(e_ C&na.4, /MU <br />, <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of co <br />(NOTE: Insurance is not mandatory) t I • tY 0 •n f rt <br />/C <br />• <br />1 t- <br />erage. <br />.1 <br />/00 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />DATE APPROVED <br />LICENSE DATES <br />APPROVED LIQUOR CONTROL DIRECTOR <br />NOTE: Do not separate these two parts, send both pans 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(8195) <br />-2 <br />