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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.STATE.MNJJS <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />NAME OF ORGANIZATION <br />(-I i -GJ C;jkv11!{'Dh- .R.1 CN P&4 <br />DATE ORGANIZED <br />-1/ANC iqt.-D, <br />TAX EXEMPT NUMBER <br />gU`7-2,62 <br />STREET ADDRESS <br />67 z;. ) Tit („4.4 'UA I (5, <br />CITY <br />lel rft (-A lvfuoA <br />STATE <br />MO <br />ZIP CODE <br />-1-57/17 <br />NAME OF PERSON MAKING APPLICATION <br />M)G1`IACL AA0Ar Liidu <br />BUSINESS PHONE <br />c->1)-ai-4-Hila <br />HOME PHONE <br />5D.';L1-1,6"L`11 <br />DATES LIQUOR WALLE SOLD <br />5 P t 1'%Aiti3k R. C,j (RC 1-1 <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE RELIGIOUS <br />aWNPP <br />OTHER -P-11-72__ <br />ORGANIZATION OFFICER'S NAME <br />P IILRM 1-- IMO)Rc< IJ <br />ADDRESS / Dr'i /SLyti bD0A ratJ1T- <br />LI n,,i.:U ctrl A1>P-1 !✓IA1 c.-3-1/ % <br />ORGANIZATION OFFICER'S NAME <br />D 4 3 %x'10 ki- AA.J <br />ADDRESS / D'3 3i_i- 4100 Is A -O ):.. <br />L) T rt. (/`%/O/#AA AA /3 Cc I / % <br />ORGANIZATION OFFICER'S NAME <br />A4 Acir a.,,-1 Pi-IOA-DSS <br />ADDRESS ),H -c-, A,l (trIS• CT. <br />VAbf\j4,5 Tic t TSJ iviiA} u`71I1'7 <br />Location license will be used. If an outdoor area, describe <br />AiAl N %bki7,L- 'L.Ik,, A's-() GcN ritWI4.-,_e R -b.. <br />LIrii.-g- cAV4 ) AAA/ *S—i <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />/\)b <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />( 1} i DL.. )1U Di-MyJiT CDM' <br />tr (-POI <br />31 `-.&cit. <br />Poi ic.R <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 CLERIC 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 -09079 (12/09) <br />