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PS-09079 (5/93) Minnesota Department of Public Safety <br />LIQUOR CONTROL DIVISION <br />190 5th St. E., St. Paul, MN 55101 <br />0....,, (612) 296 -6430 TDD (612) 297 -2100 <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 />.L777LE CAn/A09 RiCRZ*7.Tax/ AJSociAT�,0 <br />DATE ORGA IZED <br />AO7e -7 <br />NO. OF MEMBERS <br />76 <br />TAX EXEMPT NUMBER <br />019 r'C <br />STREET ADDRESS <br />S /Jr F' ,4777.4,_ C4 N4A/3 RI <br />CITY <br />,Li774f OA-v./1.64 <br />STATE <br />'Z ' <br />ZIP CODE <br />SSi/'1 <br />NAME OF PERSON MAKING APPLICATION <br />To h/a.) % /CEfS <br />BUSINESS PHONE <br />I ) ‘ 7/ -.Psoy <br />HOME PHONE <br />( ) '4/1-.2- 8)9v <br />DATES LIQUOR WILL BE SOLD? (1 TO 3 DAYS) <br />34 i2 tre / 9A '2 . / 9 93" <br />DOES ORGANIZATION HAVE A CHARTER <br />ns G Nc <br />GENERAL PURPOSE OF ORGANIZATION <br />PigOMO %Y Y04%// 4G: T,•liJ <br />ORGANIZATION OFFICER'S NAME <br />T0 f/21 ,t EI S P,1 E. CLi -Qcry i <br />ADDRESS <br />3095/ PA )-C 014. S'S if) <br />ORGANIZATION OFFICER'S NAME <br />k/9r�e. sr,raw,.9 SEcferARY <br />ADDRESS <br />.2536 mr/4,cm4,nY A- 4-- Al AI SS, /7 <br />ORGANIZATION OFFICER'S NAME <br />214).69 root.). 7 lee/ .fa 2e 2 <br />ADDRESS <br />079 -24 - c4ga.?c AC 4,,,} ss/r7 <br />Location where license will be used. If an outdoor area, describe. <br />S/YO 42TTLc rg„.AD 4 2.6 Cod ;.72a *ALA <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 />N6 <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 />YiEs ,,$TAr t= o,c /NIA,,,; fa fig 4.fJZCFj.4 'g SX PAAti <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 3 <br />