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PS -09079 (5193) Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />190 5th St. E., St. Paul, MN 55101 <br />c @-= - 9,. (612) 296 -6430 TDD (612) 297 -2100 <br />y` <br />APPLICATION AND PERMIT <br />FOR Al to 3 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />.1.IT Li !'AA. A0A nc C 1 e.A 7- 2-41 A.1 - ASSoc <br />DATE ORGANIZED <br />i ?6 K. <br />NO. OF MEMBERS <br />7r <br />TAX EXEMPT NUMBER <br />02 -1 %22 <br />STREET ADDRESS <br />.5-/m/ - r C7 72/ CA,vAAA 26 <br />CITY <br />4ZT ?/.c CA,v,94/9 <br />STATE <br />Ale/ <br />ZIP CODE <br />SS 7/7 <br />NAME OF PERSON MAKING APPLICATION <br />SOH. i. x'..."1.1 <br />BUSINESS PHONE <br />( )G7! — ease Y <br />HOME PHONE <br />( )51.2-k77Y <br />DATES LIQUOR WILL BE SOLD? 11 TO 3 DAYS) <br />CJ [?O ter /2 '7/ /9 Z%i <br />DOES ORGANIZATION HAVE A CHARTER <br />11.1-Yes Cl No <br />GENERAL PURPOSE OF ORGANIZATION <br />PAC/n OTL YO N7M 4c;; <br />OR!GANIZATION OFFICER'S NAME <br />JOL/A% 7. Xc<S Pee l SiAc-4/ <br />ADDRESS <br />3099 ASIY.✓ri AC. ma/ SS//7 <br />ORGANIZATION OFFICER'S NAME <br />keg T3t £OGX,9 StC.iRi i9,2 y <br />ADDRESS <br />02-53o MC •Did %m y ,<C, ni/v $S/ /) <br />ORGANIZATION OFFICER'S NAME <br />L.1Wd9 /A hi. Y 1-1E4 st RG2 <br />ADDRESS <br />.29.,16 14202, R9 A.C. AN SS- /a9 <br />Location where license will be used. If an outdoor area, describe. <br />-S / 3 d Hiv C VAN G r IJJ T S C HO () .L C Yn, <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 />Will the applicant carry liquor liability insurance? If so, the carrier's name and amount of coverage. <br />(Note: Insurance is not mandatory) <br />Yc5 /917AI A/C.Sp7.9 ASS1CAl ;A t.Z.C- <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 9 <br />