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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101 -5133 <br />(651) 201 -7507 Fax (651) 297 -5259 TTY (651) 282 -6555 <br />W W W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />1111-' C VOr Rj cRA -rou .bra. <br />DATE ORGANIZED <br />cl»NE i9 <br />TAX EXEMPT NUMBER <br />a94-i <br />STREET ADDRESS <br />S7 S" 4- /7" GE Cij4PA, kio- <br />CITY <br />L-RR.f 60Am <br />STATE <br />X94) <br />ZIP CODE <br />SS-) )'7 <br />NAME OF PERSON MAKING APPLICATION <br />nAtki <br />BUSINESS PHONE <br />( ) NA— <br />HOME PHONE <br />On ilkii ''lr`7a <br />DATES LIQUOR WILL BE SOLD <br />/ D/ 016J 1 <br />TYPE OF ORGANIZATION ��\ <br />CI CHARITABI F RP1 IOIOUS OTHR ONPR t <br />ORGANIZATION OFFICER'S NAME <br />f it-HA-EC 4A oKrl >v <br />ADDRESS rc1i 131&4 , co0 <br />L i Tit- I< c -NA-DA, <br />AUK - <br />A7.AJ S /r7 <br />ORGANIZATION OFFICER'S NAME <br />j »e yvIiIZeiA~+t> <br />ADDRESS IOaf L(Woo 0 ;N-V I= . <br />L r;rz.& L4'1Ai>tc, yWxJ 55"t)7 <br />ORGANIZATION OFFICER'S NAME <br />NA-itx t jHo K-5 <br />ADDRESS ' q c 3 Ak t, .4,r_ <br />VA-DNA 14 H U 1 Cd4-1i15 / /tip i t 7 <br />Location license will be used. If an outdoor area, describe <br />1> 101U E& PA-P, (APP Er)._ Roam) <br />ac S0 CMGrU r.&JIi_./. -E toA0 <br />LIY-t t Z c tt)rac/ AAA) '5 C 1 i'7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />NO <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />P I r " r , L . _ r JVDG faffr i S °���4. P4 -1r✓� 1C GPCJI l`1ha .. <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this forth to the city or county 30 days prior to event. Forward application signed by city and /or county to tiro address <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event <br />PS-09079 (05/06) <br />