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MINM:, OtA nu'U,Mt of PIM <br />SAS. IV <br />Alcohol & Gambling Enforcement <br />Name of organization <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />444 Cedar Street, Suite 222, St. Paul, MN 55101 <br />651 - 201 -7500 Fax 651- 297 -5259 TTY 651- 282 -6555 <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />St. John the Evangelist Little Canada <br />Address <br />2621 McMenemy Street <br />Name of person making application <br />City <br />Date organized <br />Jan 1, 1949 <br />Little Canada <br />John Monk <br />Date(s) of event <br />April 26th, 2013 <br />Organization officer's name <br />State <br />Tax exempt number <br />23330 <br />Minnesota <br />Business phone <br />612 -873 -7710 <br />Zip Code <br />55117 <br />Home phone <br />651- 776 -2901 <br />Type of organization <br />❑ Club ❑ Charitable ® Religious ❑ Other non - profit <br />City <br />X,J} <br />Father David Kohner <br />Little Canada <br />X <br />Mary Kay Rowan <br />Little Canada <br />Add New Officer <br />Locat on where permit will be used. If an outdoor area, describe. <br />Church and school gathering space, lunchroom and gymnasium. <br />State Zip <br />Minnesota <br />Minnesota <br />55117 <br />55117 <br />If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br />None <br />If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br />Yes, self- Insured through the Archdiocese of St. Paul and Minneapolis. Program administered by <br />Catholic Mutual (see attached certificate) <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City /County Date Approved <br />City Fee Amount Permit Date <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 <br />permit for the event. <br />Page 1 of 1 <br />