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PS-09079-0118/85) 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 />Life C1madia. ecukc Ian 1�ay3 <br />DATE ORGANIZED <br />la- I'7 -78 <br />NO. OF MEMBERS <br />)S <br />TAX EXEMPT NUMBER <br />803`432T <br />STREET ADDRESS <br />5(5 U- µ+Nam k, Rod <br />CITY <br />W-H6 Conk <br />STATE <br />NH <br />ZIP CODE <br />55K7 <br />NAME OF PERSON MAKING APPLICATION <br />I& +hieeA , Wail" <br />BUSINESS <br />I ��) BUSINESS. <br />01).) <br />HONE <br />51;3 <br />HOME PHONE <br />(oz.) u83 -3Z 62- <br />DATES LIQUOR fWILL BE SOLD? (1 TO 3 DAYS) <br />Aucsu5+ 1 - t I \C\AL <br />DOES ORGANIZATION HAVE A CHARTER <br />❑ Yes ❑ No <br />GENERAL PURPOSE OF ORGANIZATION <br />GI15 anntaI edde Coralio/\ <br />ORGANIZATION <br />OFFICER'S NAME <br />4.4(10een N. lnste.U'I Pr€Sitteni- <br />ADDRESS r <br />267a5 Edge1`-hoASt: L±-N-(eLoi.. H) ssl(7 <br />ORGANIZATION OFFICER'S NAME <br />g‘I R arc&ce.1 U) L- Presic-12-4 <br />ADDRESS <br />2o >`I \lar.60a . laid° Caul Nil ssl17 <br />ORGANIZATION OFFICER'S NAME <br />Car( IJtk,n Treasurer- <br />ADDRESS <br />dIS Vo Lin Cifffeauuut Mt3 5110 <br />Location where license will be used. If an outdoor area, describe. <br />one- POT E(I 12oc&S, (aff(e Om ak, Mid <br />, <br />Will <br />the <br />the applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor licensee providing <br />services. <br />Nl10 <br />Will the applicant carry liquor liability insurance? <br />(Note: Insurance is not mandatory) <br />l•-{alilai wa, Cri, 1330 Pcig(nlo-t- <br />If so, the carrier's name and amount of coverage. <br />Rfo, St. PwAi, 4ij 55110 so /oo/IO <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 />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 Clerk at least 30 days before the event. <br />Page 1 <br />