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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 />L 1 i FL E %'J4i1if!\- bA 0C, 1-1110/3 rrk�1%3 . <br />DATE ORGANIZED <br />J t IUr )'2i, - -Z <br />TAX EXEMPT NUMBER <br />‘R.ct` -a. (`' <br />STREET ADDRESS <br />c l C L.-I I L-)- C' l4'U AM i 0 <br />CITY <br />1-11 1 LE C4 u'i` Ak <br />STATE <br />714 0 <br />ZIP CODE <br />) 1 7 <br />NAME OF PERSON MAKING APPLICATION <br />/MiC.HA L MO ii -7-A'u <br />BUSINESS PHONE <br />( ) /U k <br />HOME PHONE <br />61)— (21- Ig— 'VlCi =: <br />DATES LIQUOR WILL BE SOLD rs,- _ <br />t i - i 5 <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOUS OTHER NONPROFIT <br />ADDRESS i 6761 Bc.. -qJ U)1�d \ ,' ) j1 -- <br />t_ i ( L1: cA- l)!a =(>.v, ; / Ai 5s (17 <br />-S)L <br />t <br />ORGANIZATION OFFICER'S NAME <br />M /CH/ E t_ Wi Qiy�t" -it) <br />ORGANIZATION OFFICERS NAME <br />ADDRESS / U' l )te c (J. W'iiJ 0 AL) G:�_ <br />ORGANIZATION OFFICER'S NAME <br />N /a -(O 6 "V k Pi /),A-i`5 3 <br />ADDRESS �, /C/4) i `5 ; . <br />VA- )JAS 13 .d I )H i 33 / i ti-� 5,_,,2'R7 <br />Location license will be used. If an outdoor area, describe ,-- <br />L]C-0 U_` tuff 1RVil,L,L Ri7, <br />LA i [ C G-1jr m. 1 Nl 1J c-3--)1 7 <br />Will the applicant contract for intoxicating liquor service? If so, gi ve the name and address of the liquor licensee providing the service. <br />/ <br />Will the app licant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />(- {{7I ToL i /Uf) i',.}VW 1 e a LR poLAC,`; nc (. --('Ul 7 )�-1 Cv 61 t- <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 />