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P5•09079 -01 (8/851 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 CN ORGANIZATION <br />ilia �¢ ��Q<% e/ Or Iorj A socvahy <br />DATE ORGANIZED <br />fen -/7- coot <br />, <br />N0. OF MEMBERS <br />7 <br />TAX E,�cEMP NUMBER <br />a 9�al <br />STREET ADD' SS <br />- 5/S . se. 4, • <br />CITY , <br />• .. <br />STATE <br />MAI <br />Y/ <br />ZIP CODE <br />S.$-// <br />NAME OF PERS0 MAKING APPLICATION <br />,Uina4 f' . FFI <br />BUSINESS PHONE <br />HOME PHONE <br />(Wel ) V%V as 7% <br />DATES LIQUOR WILL BE SOLD? 11-40 3 DAYS) <br />Qrf:• ay )99'9- <br />DOES ORGANIZATION HAVE A CHARTER <br />❑Yes 0 N <br />GENERAL PURPOSE OF ORGANIZATION <br />ORGANIZATION OFFICER'S NAME <br />.-Sieve t �orQ /4 /-2 <br />ADDRESS <br />/69' F. Rioionri <br />OR , ATION I F� R'S NAME <br />rn CC <br />ADDRESS <br />8169 E. C6 7d c <br />O GANIZATION OFFICERS E <br />irtdQ fa./iJc <br />ADDRESS / <br />c?9c71 /a.�jrc <br />Location where license will be used. If an outdoor area, describe. <br />51- John's j1' //Z (gq/wile_ Schor,/ 62y yr? <br />2 /aa1 me.J22/rverns 2'r/ LbeLe PctnGdc, , Thv ssY/7-' <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 />44 <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 />-S - Pe) 0lamard --1%s <br />J' <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 />6 <br />SIGNATURE CITY CLERK <br />Page <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 />