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oTRFSr Minnesota Department of Public Safety <br />N. 9T <br />.ate F Alcohol and Gambling Enforcement Division <br />w r 444 Cedar St -Suite 133 <br />4 DMZ, St, Paul, MN 55101 -5133 <br />_�yy ISB'Ya6:' <br />(651)296 -6439 TDD (651)282 -6555 <br />APPLICATION AND PERMIT <br />FOR A TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />�"�,t <br />os <br />` <br />OFP�B <br />s <br />at <br />� mi. <br />OFMMNE'O" <br />NAME OF ORGANIZATION <br />Little Canada Recreation Association <br />DATE ORGANIZED <br />June, 1962 <br />TAX EXEMPT NUMBER <br />29426 <br />STREET ADDRESS <br />515 E. Little Canada Road <br />CITY <br />Little Canada <br />STATE <br />MN <br />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Rick Boss <br />BUSINESS PHONE <br />( ) <br />HOME PHONE <br />(651 ) 490 -3165 <br />DATES LIQUOR WILL BE SOLD <br />10/30/99 <br />TYPE OF ORGANIZATION <br />❑ CLUB O CHARITABLE ❑RELIGIOUS MOTHER NONPROFIT <br />ORGANIZATION OFFICER S NAME <br />Rick Boss <br />ADDRESS <br />72 E. Bryan Avenue, Little Canada, MN 55117 <br />ORGANIZATION OFFICER'S NAME <br />Katie Sou ha <br />ADDRESS <br />2530 McMenemy Street. L.ttie Canada, MN 55117 <br />ORGANIZATION OFFICER S NAME <br />I nda Fahev <br />ADDRESS <br />2976 T Rnre Pnad . T.i 1-t 1 e (`anada MN 5sin <br />Location where license will be used. If an outdoor area, describe <br />St. John's School Gymnasium <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the liquor licensee 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.) not ;Ini nt nnderwri t i ng AsGnci at i nn <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />CITY /COUNTY Little Canada <br />BEFORE SUBMITTING TO ALCOHOL <br />DATE APPROVED <br />LICENSE DATES <br />& GAMBLING ENFORCEMENT <br />CITY FEE AMOUNT Waived <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED Alcohol & Gambling Enforcement Director <br />Note: Do not separate these two parts, send both parts 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 (6/98) <br />e <br />