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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, 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 />NAME OF ORGANIZATION <br />LJntE <-M' U4C7A {e. rai Af 101U kt, <br />DATE ORGANIZED <br />( -l..f /;1(6- 1 V\ <br />TAX EXEMPT NUMBER <br />Zi 4-]42v(c) <br />STREET ADDRESS <br />C) L-i 24% C'A2 /01.,A y �- <br />CITY <br />L.)r°ru (A &M' -- <br />STATE <br />✓A,w' <br />ZIP CODE <br />5 5-117 <br />NAME OF PERSON MAKING APPLICATION <br />r/ L!-) / Ct f ft AOC <br />BUSINESS PHONE <br />( »1%a/ <br />HOME PHONE <br />((n51- q`-1 cis - H 1 c i 2 <br />DATES LIQUOR WILL BE SOLD k _ <br />! "- "(rJl." ?7 "�'� -1j �! <br />TYPE OF ORGANIZATION — <br />CLUB CHAR1TABI,E RELIGIOUS OTHER ■IONNPROFIT <br />ORGANIZATION OFFICER'S NAME <br />fv iC,N1E-IL 1/1/2; _L-rA-It) <br />ADDRESS i v01. (3L--11(111200 {' , Vie , <br />L._i i i,.(1 CA- 1\JAW\ i MA) ----;5 i i 7 <br />ORGANIZATION OFFICER'S NAME <br />D1 %Fj vow L IC <br />ADDRESS I Oct Fib) w °') n A-0 <br />L, i 'Tit rc cAru/-h >/h , A4ro ‘g) -1 i 7 <br />ADDRESS ? „i 1 r n\ D J_bril. j <br />vAj>iv i5 i- i>✓,-i&1-1 '>, m iv S i Z7 <br />ORGANIZATION OFFICER'S NAME <br />f A ucy - dUIVLi `� <br />Location license will be used. If an outdoor area, describe s <br />DMLL- F 1 cL-f) .-{- t _owif f-.. F f 'l Ul>,'N) 1-400 } LI 4-.<2 <br />1..-- i Ltt c >ot -C-bA f MC SS, 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 />7) v <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />^� <br />u P i 10L..- i ?L.) D {y Y`A it)1 1 ts, f) KR Pea, cL 6--Poi ,1 ` i CR <� <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 form to the city or county 30 days prior to event. Forward application signed by city and /or county to the 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 (12/09) <br />