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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, St, Paul MN 551015133 <br />(651) 201 -7507 Fax (651) 297.5259 TTY (651) 282 -6555 <br />W W W.DPS,STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 'CO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />Saint John's Church of Little Canada <br />DATE ORGANIZED <br />1851 <br />TAX EXEMPT NUMBER <br />23330 <br />STREET ADDRESS <br />380 Little Canada Road <br />CITY <br />Little Canada <br />STATE <br />Minnesota <br />ZIP CODE <br />55117 <br />NAME OF PERSON MAKING APPLICATION <br />Father Thomas Balluff <br />BUSINESS PHONE <br />&51) 484 -2708 <br />HOME PHONE <br />( ) <br />DATES LIQUOR WILL BE SOLD <br />Apri 1 11 2014 <br />TYPE OF ORGANIZATION <br />CI [1B CHAR TABLE T>1 I0i011S OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />Father Thomas Balluff <br />ADDRESS <br />same <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location license will be used. If an outdoor area, describe <br />school lunchroom and gymnasium/ Men's Club Fish Fry <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />yes Self insured through Archdiocese of St. Paul /Mpls. (Catholic Mutual) <br />APPROVAL <br />APPLICATION MUST T31t1 APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY /COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL Be GAMBLING <br />CITY FEB AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERIC OR COUNTY OFFICIAL APPROVED DIRECTOR AI.COH01. AND GAMMANG ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and /or county to the address <br />above. If the application Is approved the Alcohol and Gambling Enforeeownt Division will return this application to be used as the License for the event <br />P5-09079 (12/09) <br />