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Minnesota Department of Public Safety <br />Oft*. LIQUOR CONTROL DIVISION <br />444 Cedar St. /Suite 100L <br />`. St. Paul, MN 55101 -2156 <br />(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 />LICENSE <br />r r., <br />*% <br />la <br />or <br />MB I# <br />NAME OF ORGANIZATION <br />.L22T TLY ('4mp4A t.C/Pf/LT,4.e!✓ Acsci <br />DATE ORGANIZED <br />/.G / /)/6 2 <br />TAX EXEMPT NUMBER <br />02 951 6 t <br />STREET ADDRESS <br />c.15 r •c.r -TTY -h CAN444 12 A <br />CITY <br />C i I'LL CA.v4AA <br />STATE <br />/h Al <br />ZIP CODE <br />S$' // 1 <br />NAME OF PERSON MAKING APPLICATION <br />;re HA) T /(EZC <br />BUSINESS PHONE <br />Viz.) 67/- o2S051 <br />HOME PHONE <br />(o /A VtZ-S-17Y <br />DATES LIQII R WILL BE SOL (1 to 4 days) <br />s%id 94 — e-////96 <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE ❑ RELIGIOUS VOTHER NONPROFIT <br />ORGAf�IZA ION OFFICER'S NAME <br />.icii/xi «e; <br />ADDRESS <br />391 PA'v. LC rnN S'S//] <br />ORGANIZATION OFFICER'S NAME <br />ki4i -L Sc c'pm) <br />ADDRESS <br />,)S3Q mvnFr'7r my 2 C aN SS // <br />ORGANIZATION OFFICER'S NAME <br />47,NA4 f ^HbV <br />ADDRESS <br />o77-2t A/4R,i2N /2L 2e— mN SS /Q f <br />Location where license will be used. If an outdoor area, describe <br />SPodn/r Z P9rt?IL btTJLG C4NAA/9 <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor license providing the service. <br />N0 <br />Will the applicant carry liquor liability insurance? If so, the carrier' s name and amount of coverage. VI: C <br />(NOTE: Insurance isnotmandatory) .S'iAi i c3' M..Na>i-,1'eJ/ -t ASj,yG..terA -ZS C PI Am <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 <br />will be returned as the license. Submit to the City <br />the <br />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 60 <br />