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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, St. Paul MN 55101 -5133 <br />(651) 201 -7507 Fax (651) 297-5259 TTY (651) 282 -6555 <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 />• <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />Saint John' s Church of Little Canada. <br />DATE ORGANIZED <br />1851 <br />FAX EXEMPT NUMBER <br />ES 23330 <br />STREET ADDRESS <br />380 Little Canada Road East <br />CITY <br />Little Canada <br />STATE <br />Mn <br />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rev. David Kohner <br />BUSINESS PHONE <br />(51.) 484-2708 <br />HOME PHONE <br />( ) same <br />DATES LIQUOR WILL BE SOLD <br />Fridav September 14 2012 <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RFlICOUS OTHERNONPROPIT <br />ORGANIZATION OFFICER'S NAME <br />Rev. David Kohner <br />ADDRESS <br />380 Little Canada Road St. Paul, Mn. 55117 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />Location license will be used. If an outdoor area, describe <br />school gymnasium — Spaghetti Dinner <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />no <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />yes Catholic Mutual <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />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 ALCOUOL 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 />PS-09079 (12/09) <br />