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Minnesota Department of Public Safety <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 TTY (651) 282-6555 <br />W W W.DPS.S'T'ATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />NAME OF ORGANIZATION <br />1,171 l= c:,AippDA. .,�j cJEftION A5SK). <br />DATE ORGANIZED <br />jar/'3Ia /162 <br />TAX EXEMPT NUMBER <br />aC'1 <br />STREET ADDRESS <br />CITY <br />[.i 1 i E 6,/rAApAc <br />STATE <br />rA tai <br />ZIP CODE <br />5' 5 11/7 <br />5--//. bin --1-r.: c A-TvApA P4) <br />NAME OF PERSON MAKING APPLICATION <br />1 CSI -1 At L- MOf c.71\/ <br />BUSINESS PHONE <br />'650 - a -J-6- -1 P\ <br />HOME PHONE <br />(4.5!)' a,--1 `fir) -(bra <br />DATES LIQUOR WILL BE SOLDy <br />Ai�Lll'oq 1 — ? O,"1 1 <br />TYPE OF ORGANIZATION <br />CI11111CHARITABLE RELIGIOUS <br />OTHER T�PRSj1'� <br />/ <br />ORGANIZATION OFFICER'S NAME <br />M 1ci-1 AL I- MO( LAY\) <br />ADDRESS / 0(7 13C.tt i_ t2Ol) AUe, <br />1_ ,r i -,_l °tyro/AOA wt/U c & ! -i <br />ORGANIZATION OFFICER'S NAME <br />()L8 mo REt./r4) <br />ADDRESS <br />/ 0 CI OCA.- /A200 b A-Ule . <br />L ri i ur_ ck&)//J>k IM 4) C: %1 7 <br />ORGANIZATION OFFICER'S NAME <br />NkNc-ue del-ivfUf,-i <br />ADDRESS -5,153 AIVO 1. % t <br />VA0/vOI-2 T -,F -I(4 -I1-4, /v ccia7 <br />Location license will be used. If an outdoor area, describe <br />SPuc)N(E2, Plea -g <br />L4PPr-_4_ -- l;0(-)1 3 C rLi R.D. <br />5A -u- F1cLoc) L - IT -r7 -G- (JkYk'P/v,AAA/ Sfri7 <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />WD <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />LAP' i 0L.-. ! N (J li-Yvt N 1 f Y CD R P. Ry ic:'-t # C PO r$ I /-1(09-- <br />-1((9APPROVAL <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY <br />ENFORCEMENT <br />CITY/COUNTY <br />BEFORE SUBMITTING <br />DATE APPROVED <br />LICENSE DATES <br />TO ALCOHOL & GAMBLING <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING 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 Enforcement Division will return this application to be used as the License for the event <br />PS -09070 (12/09) <br />