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Minnesota Department of Public Safety <br />�oFt!'E•s?a LIQUOR CONTROL DIVISION <br />yt <br />tzo,10� 444 Cedar St. /Suite 100L <br />St. Paul, MN 55101 -2156 <br />(612)296 -6439 TDD (612)282 -6555 <br />.114, <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 period <br />TYPE OR PRINT INFORMATION <br />LICENSE <br />'r� t\ <br />*�a <br />V <br />"'�-,.F�' <br />or <br />MBI# <br />NAME OF ORGANIZATION <br />4177AZ CA✓.A44 n2cCiel 7 -te+J 4S(QC.lA %Jt• <br />DATE ORGANIZED <br />.i1 NG /94.2 <br />TAX gEXEMPT NUMBER <br />� / ya 6 <br />S FREE I ADDRESS <br />S/S r L�77 Ce.”nn/� • Rn <br />CITY <br />/.17-74.6 cm-AAA <br />STATE <br />m n/ <br />ZIP CODE <br />TT,/ 7 <br />NAME OF PERSON MAKING APPLICATION <br />So 111•-' T K ,r-7. <br />BUSINESS PHONE <br />( ) / 7/ - 0250 V <br />HOME PHONE <br />( ) «e-1 f 7 7 y <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />✓ 02 g- ) 02 9 J u nit" / 9 9 7 <br />TYPE OF ORGANIZATION , <br />0 CLUB 0 CHARITABLE 0 RELIGIOUS rOTHER NONPROFIT <br />ORGANIZATION OFFICERS NAME <br />.To/7N KC1,S <br />ADDRESS _ <br />.q09 Y PA Y✓vc /9✓I 1.c ni AJ CS /I7 <br />ORGANIZATION OFFICER'S NAME <br />KA✓—jr COCf - //J <br />ADDRESS <br />?S30 /nemj= ✓ir. "m'/ AG 'n n- Ss'//7 <br />ORGANIZATION OFFICER'S NAME <br />.(. 2 .v 11,4 f4 fr/z\:/ <br />ADDRESS <br />0? (3.? G L. A 3 c).2 •% s i) ,L L. rh .v .a S la 9 <br />Location where license will be used. If an outdoor area, describe <br />?zeo✓r_"E,Z ?A ✓(K „? 1 So Cr iv:.czt/Jacr_ ,2/.A 47 7 4/ C.44/1QA/3 <br />in 4/ SS/ /7 <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) <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(8/95) <br />Page 152 <br />