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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 />NAME OF ORGANIZATION <br />i i l % L»iM 1 RS.caMr-tvi A-% t;4t c* <br />DATE ORGANIZED <br />:Twig.- I eklo; <br />TAX EXEMPT NUMBER <br />a°11`I a c <br />STREET ADDRESS <br />C (5 L l r17 C.AUAbA- RI) . <br />CITY <br />ii I ItL) ClN orNic <br />STATE <br />N lU <br />ZIP CODE <br />515-) l '7 <br />NAME OF PERSON MAKING APPLICATION <br />/Ai i cm Ai (., Molk!✓LAtLI <br />BUSINESS PHONE <br />(I'S))--aw /=6- `-lick <br />HOME PHONE <br />(C;51)-a`=-i —1.-iirja <br />DATES LIQUOR WILL BE SOLD, <br />/TrRI� / �-n t a t �7 <br />V <br />CLUBOFCHARITABLE, O RELIGIOUS OTHER ONPR 1 <br />ORGANIZATION OFFICER'S NAME <br />M1LHM M>ic-L%4a) <br />ADDRESS i f201 64_,L4 7 0 pcuic,; -_- . <br />L l K rt-t CA- vu/',D/j MYV >5)17 <br />ORGANIZATION OFFICERS NAME <br />0 r..7 i3 MOikG`�( A4 <br />ADDRESS i 0 q (j[_,IAWvu0 iU6` <br />L t TT -t. - e A- NA -P/6,/ 1/v4 9V S: ) 17 <br />ORGANIZATION OFFICER'S NAME <br />ivAAA:, •Lii jtho/ PE CS <br />ADDRESS 3/i c5 3 A.. e..„A..De 5i <br />l/, CL NPrl'5 t- Irl&i447-57 i4;i} 1 i <br />Location license will be used. If an outdoor area, describe <br />FuCNTr‘ Cc2>i ---LPs <br />Q,ulco PIC1 5°. <br />CI �--LETCAI» %V* MN ?ASS1l5 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />IV '0 <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />PI -MI._ 1NN PA1/I1 CO'r4t). i-OLK,»; A--C,\>0 i31LI c�2 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY /COUNTY DATE APPROVED <br />CITY FEE AMOUNT LICENSE DATES <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL 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 />I'S -09079 (12/09) <br />