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Minnesota Department of Public Safety <br />d°w1'n1'i' <br />o.• LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100L <br />St. Paul, MN 55101 -2156 <br />a (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 period <br />TYPE OR PRINT INFORMATION <br />a� �%\r. <br />A -yak <br />LICENSE <br />or <br />MBI# <br />NAME OF ORGANIZATION <br />1177 L.r (q,/AA/9 REC.�2r- A71aa/ AS1oc. <br />DATE ORGANIZED <br />JUN9 /9t2 <br />TAX EXEMPT NUMBER <br />a 9 1/42 d' <br />STREET ADDRESS <br />xis 1. 4ZTrL..5 C,Qwrn4,9 Rb <br />CITY <br />/trr l.i, rA,Mh4 <br />STATE ll ZIP CODE <br />m.v 3"Sii7 <br />NAME OF PERSON MAKING APPLICATION <br />M NA■ K c a - s <br />BUSINESS PHONE <br />( G / . 2 ; $ 6 7 / -02 s o V <br />HOME PHONE <br />(t /2) v fa - g 2 7 4 1 <br />DATES LIQUOR WILL BE SOLD (I to 4 days) <br />TA 4, / 7 -J2 J 9 9 Q- <br />TYPE OF ORGANIZATION <br />0 CLUB ❑ CHARITABLE ❑ RELIGIOUS IraTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />TORN K °7S <br />ADDRESS <br />Rooi1 PA>ovi. Av%' AC ry,.v g //7 <br />ORGANIZATION OFFICER'S NAME <br />IK.9r 27-3 soCw'9 <br />ADDRESS <br />c2530 fit cen c.✓tr+ y L C. m.1..; .S5 i/ 7 <br />ORGANIZATION OFFICER'S NAME <br />A= $^'A.4 f=AwiY <br />ADDRESS <br />a9az .CA <3aR.L f2A Lc- mn. S'S/al <br />Location where license will be used. If an outdoor area, describe <br />VA/ fi J -rrrL/ CANAQA R Q L%77di� CA4 v44.4 .»N c,s-n? <br />/,.G 04-A jr i:/L? H/J.. r <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) NN.= 5 c 7/9 A.CS _rC iJ A fi . -.SK <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CTFY 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 45 <br />