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PS- 09079 - 0118/851 MINNESOTA DEPARTMENT OF PUBLIC SAFETY <br />PHONE612- 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 />NAVE OF ORGANIZATION <br />/./ /e Canada. �erfeAd a i 12szocia- /t <br />DATE ORGANIZED <br />/02- /7 -L0)- <br />NO. OF MEMBERS <br />77 <br />TAX EXEMPT <br />079/ <br />STATE <br />/72..) <br />NUMBER <br />p2� <br />ZIP CODE <br />SS // 7 <br />STREET ADDRESS <br />5 /,S' 2i 414 deeiodo �ifd <br />CI Y /J <br />i%//7 C,anacle... <br />NA OF PERSON MAKING APPLI ATION <br />k,.,da- it F�h67 <br />USINESS PHONE <br />I ) <br />HOME PHONE <br />6/01 ) 8y 0257 5 <br />DATES LIQUOR WILL BE SOLD? (1 TO 3 D ) <br />(f e.-6 . 36 . /97, -3 <br />DOES ORGANIZATION HAVE A CHARTER <br />❑ Yes p-No <br />NERAL PURPOSE OF ORGANIZATION <br />Et) Po b /&M ACIia' /v . <br />ORG <br />-JO <br />NIZATION OFFIpErS NAME <br />hn /Spin <br />, <br />ADDRESS <br />009 LA t291int igia <br />ORG/j2N'bt TION OFFICSOSNAME > <br />ADDRESS <br />/ <br />253o 1'7a fin ,) -` YQs <br />0�lfJ1l� h''ZCCATIQO..N OFFI R'C,] E <br />ADDRESS /j��'/� <br />/ <br />g/ ca p iirah/L. % 'i <br />Location where license will be used. If an outdoor area, describe. <br />St /O hp .s /Cis ` c C G%) DC�/ Gy m <br />Vc,a.1%'YIc- ig/IEr t�-5 I ,Le N Cvrr o /')n) ,ssw7 <br />, <br />Will the <br />the services. <br />applicant contract for intoxicating liquor services? If so, give the name and address of the Liquor licensee providing <br />() <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 />9Es — Mc -ha, nxtra Is <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 33 <br />