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Minnesota Department of Public Sakty <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222„ St. Paul MN 55101-5133 <br />(651) 201-7507 Fax (651) 297-5259 Try (651) 282-6555 <br />WWW.DPS.STATE.MN.US <br />APPLICATION AND pEamyr <br />FOR A 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />'' " <br />NAME OF ORGANIZATION <br />11...r, Q1/410ArA r<::;;----ki.:.f: ;NT ;1/4;1 A..5Ci)tki. <br />DATE OR GAN I zno <br />11.,(A)i ',. SOPs <br />CITY <br />/.4771.r. LA-AAP:\ <br />FAX EXEMPT <br />dsi"i 41.-/ <br />STATE <br />i'44-) <br />NUMBER <br />ZIP CODE <br />C<-..; i <br />STREET ADDRESS <br />.c L / Ili( 6,4A)M54 RD, <br />NAME OF PERSON MAKING APPLICATION <br />[41 CHA ET 1-, mo RiTz..i id <br />BUSINESS PHONE <br />(. ) fox <br />TYPE OF ORGANIZATION <br />CLUB ClilARITA Et I" RELIG10115 <br />ADDRESS t (L.„ Of k,t, c4 <br />'LA -1r L, ii, CAJUA <br />HOME PHONE <br />Vyi ) <br />OTHER(NONP RA:ATV <br />vio ON hoi r. <br />V" A- M i',.) . t:1) / ( 7 <br />DATES LIQUOR WILL BE SOLD r <br />i 4:1- 1 A ./ j <br />r Ic---l.2) • i •-',(••••:; i --I <br />1 <br />ORGANIZATION OFFICER'S NAME <br />rAi (..,H k-., L. mo izEb\k) <br />ORGANIZATION OFFICER'S NAME <br />Di :1..., I■40 RETLAP <br />. DDRI SS <br />/ OzTy ift,3 C.. q L4-'0( ) /5 Ad) ri, <br />L -,--- -1-- i C: C...kiq N> flz, riji ic,c 5 1 1 ;7 <br />ADDRESS 3/16-3 Aps_A07; <br />v A- 0 AA IS H ii:h 6., fri -/3 2 Rit.q) C.:3--15- f•R, 2 <br />ORGANIZATION OFFICER'S NAME <br />IWVIC i (I t-X. R Ho NiyEic::, <br />Location license will be used. If an outdoor area, describe <br />r) L.. (7) , I 1? r 1--t b\-?.....L G <br />5. - V f7 \ ±-> i-IP \ k-:E: ( 010 <br />H ) L., 1 , I '''' L.. 1: CAW Al*. Lt. a?1;);) <br />1- i V"1.L.-E.: CA,,,A05 k ; -iv 0 SzS7i 7 L <br />1 7-1LJ--: CAMibiL: i IN 1\ ) 55 <br />give the name and address of the liquor licenSOC providing the service. <br />Will the implicant contract for intoxicating liquor service? If so, <br />r \lc\ <br />the carrier's name and amount Of coverage. <br />will the applicant carry liquor liability insurance? If so, please provide <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />C1TY/COUN1'Y <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL <br />84 GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SD:NATI:RE an, CLAM OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />. . .. . ., <br />NO I. Is: Submit this form to the city or county 30 days prior to event. Forwani apt) ICd 1011 stgaet y et ) at .. loore» <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this ;Application to be used SS 1110 License for the 0'011 <br />Ps-09079 (12/09) <br />