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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, 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 I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />I Y lib UK I'KIN 1 INI'UISIVIn 1IVIN <br />NAME OF ORGANIZATION <br />LitILE. CANADA 14U2FATlOr3 ASS <br />DATE ORGANIZED <br />SEA osa IHb'L <br />TAX EXEMPT NUMBER <br />2992 -G <br />STREET ADDRESS <br />c/ C LI IT 1.L. C/t7JY) 6,4 2i <br />CITY <br />bra M IA <br />STATE <br />✓r i\J <br />ZIP CODE <br />s C I 1 7 <br />NAME OF PERSON MAKING APPLICATION <br />TivnotAi -Zn2Eme);. -S ic; <br />BUSINESS PHONE <br />(& ,0)LicBG.'o4,6 <br />HOME PHONE <br />(6‘..-/) 4.63 25) <br />DATES LIQUOR WILL BE SOLD <br />f' E8/2- (4*2 -r fa. ruAs 2-01 •3 <br />TYPE OF ORGANIZATION <br />CI LIB CHARITABC.F RV; GIOUS OTHER NONPROFIT <br />ORGANIZATION OPPICEt NAME <br />• 1t Ao +h. • ZA-( .- n,'3i,I S t <br />ADDRESS 3,0 24 c FL'„ dt9 h2 t✓ Al <br />G-/YTLe. C/`/'J'ii. /A /✓//x) Ss-/0 C/ <br />ORGANI" ATIONN OFFICER'S NAME <br />ICE & I a.. L ,, <br />ADDRESS / 0 9 L t ( „die A At/61 <br />(r fl- c..L C4i-,- d 14 mfri s5 / / 7 <br />ADDRESS 3L.1S . 4.4,c A. 21 E_ s r• <br />QAP/J/9 -�S He /v /ITC /v1A ,( / 7 <br />ORGANIZATION OFFICER'S NAME <br />ktiC_. R1 -\cD'M ' -5 <br />Location licen will be used. If an outdoor area, describe I R 1�C--, (9 ct` , A 1 S eouh.T4 <br />no 2 <br />Y <br />— • <br />� n g, b (�V2 Th <br />--.ITt C.E CAYN -At!' M r) SS I f 2 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />/AAv D <br />Will the applicant carry liquor liability insurance`? If so, please provide the carrier's name and amount of coverage. <br />CAP17 -OL / %41aEvY■J i 'T v 62 - Potu # C P0131 Lob 9?- <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 />APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />1 6 cit an'l /or enmity to the address <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward ......1:...41.“ t t stguet y y <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 (05/06) <br />