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gTnssr Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />F'ti:„,_ � 444 Cedar St —Suite 133 <br />St Paul, MN 55101 -5133 <br />a58_MINNE <br />...I. Y i <br />*� <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 />�oF, a, <br />,e� .;� <br />° ►I�-k�f <br />�a <br />op <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 R Tittle Canada Road <br />CITY <br />Little Canada <br />STATE <br />MN <br />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Tnhn Keis <br />BUSINESS PHONE <br />( Al) A,71 -95(14 <br />HOME PHONE <br />(FAA) dR ? —P774 <br />DATES LIQUOR WILL BE SOLD <br />October 24, 1998 <br />TYPE OF ORGANIZATION <br />❑ CLUB ECHARITABLE ❑RELIGIOUS,]OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />John Keis <br />ADDRESS <br />3094 Payne Avenue. Tittle Canada MN 55117 <br />ORGANIZATION OFFICER'S NAME <br />Katie Soucha <br />ADDRESS <br />2530 McMenemy Road, Little Canada. MN 55117 <br />ORGANIZATION OFFICER'S NAME <br />Tinda Fahey <br />ADDRESS <br />2q7A. T.n1=knrA, Rnnri Lit•t1n r'anarla MN S51llq <br />Location where license will be used. If an outdoor area, describe <br />St. John's School Gymnasium <br />2621 McMenemy Road <br />Little Canada, MN 5.511/ <br />Will the applicant contract for intoxicating liquor services? 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, the carrier's name and amount of coverage. <br />(NO It: Insurance is not mandatory.) MN Jnint TTnderwri t i ng Assnr i at i On <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING ENFORCEMENT <br />CITY /COUNTY Little Canada DATE APPROVED <br />CITY FEE AMOUNT Waived LICENSE DATES <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 />Page 19 <br />