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PS- 09079 - 01181851 MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />PHONE 612- 296 -6159 LIQUOR CONTROL DIVISION <br />333 SIBLEY • ST. PAUL, MN 55101 <br />APPLICATION AND PERMIT <br />FOR A 1 to 3 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />'St, 3c;hr;s C\\urcl-, <br />DATE ORGANIZED <br />1is5)3 <br />NO. OF MEMBERS <br />a000 <br />TAX EXEMPT NUMBER <br />g91 83■7 <br />STREET ADDRESS I <br />3 O E . l.,it --fla Ccarlrr(z Rd. <br />CITY <br />L)+*Ie. Cc{rrcjea. <br />STATE <br />Mr\. <br />ZIP CODE <br />SS-11-7 <br />NAME OF PERSON MAKING APPLICATION <br />G:r\a-k -te LIRtl',er. <br />BUSINESS PHONE <br />ltola' & fl-a :o8 <br />HOME PHONE <br />(LIa) 1 ) q - la(L <br />DATES LIQUOR WILL BE SOLD? (1 TO 3 DAYS) <br />I\1 greh S t'l00 <br />DOES ORGANIZAT ON HAVE A CHARTER <br />❑Yes ' No <br />GENERAL PURPOSE OF ORGANIZATION <br />NON —9 RloC- it <br />ORGANIZATION OFFICER'S NAME V <br />Re.U„ RnkerT - .%*4pccr 10i< <br />ADDRESS <br />3$0 E, l.,',i- -\ \e CCAr\cadcc Rd <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location where license will be used. If an outdoor area, describe. <br />t. ;S<)hnst 5chnot - Lower LeieI <br />sq e nK w'sna Ono IerS <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor licensee providing <br />the services. <br />no <br />Will the applicant carry liquor liability insurance? If so, the carrier's name and amount of coverage. <br />(Note: insurance is not mandatory) <br />yes Cca'ikoLe (Ro-l-ucd (3n1'tC� MI 79Qa <br />, <br />APPROVAL <br />CITY OF <br />DATE APPROVED <br />CITY FEE AMOUNT <br />LICENSE DATES <br />DATE FEE PAID <br />APPROVED LIQUOR CONTROL DIRECTOR <br />SIGNATURE CITY CLERK <br />Do not separate these two parts, send both parts to the address above and the original signed by this division <br />NOTE: will be returned as the license. Submit to the City Clerk at least 30 days before the event. <br />page -8- <br />