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Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />,o,... 444 Cedar St. /Suite 100L <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 <br />(Organization or location limited to 3 permits in a 12 month periodf$q <br />TYPE OR PRINT INFORMATION <br />LICENSE <br />�/�r <br />A *ye. <br />or <br />MBI# <br />NAME OF ORGANIZATION <br />A i rLrte C4N/ I) ,Q&j2ti -r. ,v ,4Cso'. <br />DATE ORGANIZED <br />Ttgivr /U2 <br />TAX EXEMPT NUMBER <br />aq y 0 6 <br />STREET ADDRESS <br />.C/S c- ACC 77-4.2. 0/4,.,444 g 6 <br />CITY <br />h7•rrIr_ C4 4M <br />STATE <br />/v+ n-) <br />ZIP CODE <br />Sir JJ 7 <br />NAME OF PERSON MAKING APPLICATION <br />SC-1/4r 7' /CG S <br />BUSINESS PHONE <br />/->J 0/ - aSo5' <br />HOME PHONE <br />(632) yla- ?D7 y <br />DATES LIQUOR WILL G BE SOLD (1 to 4 days) <br />AU (, q,s /` 0 - 9 <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE ❑ RELIGIOUS e0THER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />Jdylt/ /05:1--C <br />ADDRESS <br />,309'`/ PA ..-Iii:' 4 U , z C '+t✓ Ss D7 <br />ORGANIZATION OFFICER'S NAME <br />A-1r9rt/' SCCh///i <br />ADDRESS <br />.25" So niC- /%'1%/vj/% `/ AC. ofN ; -S- /)7 <br />ORGANIZATION OFFICER'S NAME <br />,A.T•/v 1,9 /A).th- Se <br />ADDRESS <br />a9026 A4S RG ad A- C- m,t 5-,5709 <br />Location where license will be used. If an outdoor area, describe <br />- • . <br />J1 / C n S/ <br />SPoe/,:- -A ,4R14 <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />iV 0 <br />Will the applicant carry liquor liability insurance? If so. the carrier' s name and amount of coverage. <br />( NOTE: Insurance is not mandatory) m rN av •cr A% 4 76 j' N T u N Q.C2 w,e 1 7j--.° d ,4 4" SO c <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 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 />Page 4 <br />