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Minnesota Department of Public Safety <br />orate LIQUOR CONTROL DIVISION <br />Av. 3 <br />° 444 Cedar St. /Suite 100L <br />•i �z? St. Paul, MN 55101-2156 <br />�I d (612)296 -6439 TDD (612)282-6555 <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR <br />(Organization or location limited to 3 permits in a 12 month period <br />TYPE OR PRINT INFORMATION <br />LICENSE <br />)S$4 <br />�"^e <br />�/�* r <br />A= <br />" „�� ' <br />�” �I3 °S� <br />4177 - C. o -q 1/ 3 <br />Or <br />MBI# <br />NAME OF ORGANIZATION <br />C. /Sic ea n 0.41A IZecrrcthof 4330e,,c,t,on L,e <br />DATE ORGANIZED <br />Sw'ne. i ^itea <br />TAX EXEMPT NUMBER <br />9CLJQc <br />STREET ADDRESS <br />S)S . Z.tt±/e C'ancdk .Rd. <br />CITY <br />L.t-I-le Cati4ia, <br />STATE <br />In ✓ <br />ZIP CODE <br />SSW i <br />NAME OF PERSON MAKING APPLICATION <br />Rtc.(C BOSS <br />BUSINESS PHONE <br />( ) <br />HOME PHONE <br />((4S7) 4y0 -3/6 <br />DATES LIQUOR WILL BE SOLD (I to 4 days) <br />4v'uST `/, Si 4= <br />TYPE OF ORGANIZATION <br />❑ CLUB 0 CHARITABLE TI RELIGIOUS I( OTHERNONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />'Rlc- . 3a5S <br />ADDRESS <br />9 C 3arAa 5, . Lift - /e Co.,... .-aes m,./ Y557/7 <br />ORGANIZATION OFFICER'S NAME <br />je..L+ie So ✓c.kct, <br />ADDRESS <br />o :30 Plc;VL:.;,<_.ry 4T. L,ffW CKn44h frorj fro CS"? <br />ORGANIZATION OFFICERS NAME <br />L, n del, Fa.t-e <br />ADDRESS <br />31Oi¢ Lc:Boc e RS.., 4 flee Cu.w.,dc , Mrs. S5/01 <br />Location where license will'be used. If an outdoor area, describe <br />SPoo, -e k. PaaK L, lit/ e. LG-rtG. d0. in ti '3 5'117 <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 coverage. <br />(NOTE: Insurance is not mandatory) MA/• .SOikr v i1/410<4. La rat , Ex MS ✓ei.thov' <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 />NOTE: Do not separate these two parts, send both parts to <br />will he returned as the license. Submit to the City <br />the <br />or County <br />address above and the original signed by this division <br />at least 30 days before the event. <br />PS- 09079(8/95) <br />Page 14 <br />