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TYPE OR PRINT <br />Minnesota Department of Public Safety <br />'Ei% LIQUOR CONTROL DIVISION <br />"�' °»+� 444 Cedar St. /Suite I00Lr- <br />St. Paul, MN 55101 -2156 <br />4' (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 />INFORMATION <br />LICENSE <br />A *fa <br />� <br />or <br />MHI# <br />NAME OF ORGANIZATION <br />._b%7.0 di- r4,vA/)/a ,Z r. c, F/J- -aoo/v AEI(i- <br />DATE ORGANIZED <br />/;.9 /,7 /&a <br />TAX EXEMPT NUMBER <br />&9 '/62 <br />STREET ADDRESS <br />ur /.C. /_. /.117tic 04.vA -4,4 ;z/) <br />CITY <br />R- ii -rAc cA,V40' <br />STATE <br />n4 A.) <br />ZIP CODE <br />SS //7 <br />NAME OF PERSON MAKING APPLICATION <br />aGHOV i 7(ci,- <br />BUSINESS PHONE <br />( ) 6 7/- .2 SoY <br />HOME PHONE <br />( ) /S.2- F77`/ <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) <br />/d ,2c 9 L <br />TYPE OF ORGANIZATION <br />❑ CLUB ❑ CHARITABLE ❑ RELIGIOUS OTHER NONPROFIT <br />ORGANI ZATION OFFICERS NAME <br />7..±5-4/ .4,/ ./ A' 'En- <br />ADDRESS <br />209'/ ACYNj /41/rzil .0 C- mN s'.S// % <br />ORGANIZATION OFFICER'S NAME <br />)C, ill ri SGCN./A <br />ADDRESS <br />.2530 Mc: m tEV G✓?Y 4L. miN 5 //7 <br />ORGANIZATION OFFICER'S NAME <br />.1. 3-.v A A FAHr Y <br />ADDRESS <br />.) 9a L A 4r?0,27., i2) 2. C m ry CS /U ? <br />Location where license will be used. If an outdoor area, describe <br />,S 7- . roIN'.S .C( / - /OOL „/ GgL/ inc M/d AJ,,n'Y R A <br />L;ryLr_ 04.'1444 Mr' S5.7/7 <br />Will the applicant contract for intoxicating liquor services? If so, give the natne and address of the Liquor license providing the service. <br />AJ r': <br />Will the applicant <br />(NOTE: Insurance <br />cam' liquor liability insurance? If so, the carrier' s name and amount of coverage. <br />is not mandatory) ,S i A r/3 0 /' M LNN - s e rA i4 S J .ZC,.vr L ?2S G Ph 4A/ <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY /COUNTY <br />CITY FEE <br />DATE FEE <br />DATE APPROVED <br />LICENSE DATES <br />AMOUNT <br />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 6 <br />