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Minnesota Department of Public Safety <br />scr LIQUOR CONTROL DIVISION <br />• 444 Cedar St. /Suite 100L <br />fl St. Paul, MN 55101 -2156 <br />k5 <br />(612)296 -6439 TDD (612)282 -6555 <br />� �t <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)c <br />TYPE OR PRINT INFORMATION <br />LICENSE <br />r*`\ <br />*�� <br />��'` <br />a ? = <br />or <br />MBI# <br />NAME OF ORGANIZATION <br />4-317711E CAA/A6ff Zttt€r 97yooJ Arsoc <br />DATE ORGANIZED <br />/c)//7/G -2 <br />TAX EXEMPT NUMBER <br />o2 9 y-z ‘ <br />STREET ADDRESS <br />S-7-S- E ksiT4e. C4 -9A 9 Pb <br />CITY <br />4.5:77&L C9p.AOn <br />STATE <br />m ,v <br />ZIP CODE <br />SS /17 <br />NAME OF PERSON MAKING APPLICATION <br />50,4/v XLYS <br />BUSINESS PHONE <br />( ) G71-a?Satl <br />HOME PHONE <br />( ) 1 - 2 -277Y <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />/// f/ 9 7 — /// 9/9 % <br />TYPE OF ORGANIZATION <br />0 CLUB 0 CHARITABLE 0 RELIGIOUS 'OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />To,vN /C rC P2Cs.24,;;NY <br />ADDRESS <br />3C 9 K PAyN.c Rai- L c-- m N S SI17 <br />ORGANIZATION OFFICER'S NAME <br />/69. Y sf 0 G/-//9 sI- 7c2 ETA A9 <br />ADDRESS <br />-?S3 0 many:: ,tLE'wiV k C- 44..1 SS /l7 <br />ORGANIZATION OFFICER'S NAME <br />.4 I", .)/9. h9HCY 1 Ri9,Ct4it.r/. <br />ADDRESS <br />-29ac La26AZ A6 i- c MA? Ss/a9 <br />Location where license will be used. If an outdoor area, describe <br />LliizG CAN AA/9 aca / =iit1 t/i9c'- <br />V41 o £ /Ctn. is CAo.i4Aa iZA <br />C C MA) .5C //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 />N6 <br />Will the applicant carry liquor liability insurance? If so, the carrier s name and amount of coverage. <br />(NOTE: Insurance is not mandatory) v / C C .i i A i .c , Y M it) ,4 .C.fi 0'N r 4\ AJ.sw P Z4 N <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 <br />will be returned as the license. Submit to the City or County <br />address above and the original signed by this division <br />at least 30 days before the event. <br />PS- 09079(8/95) <br />Page 63 <br />