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Alcohol & Gambling Enforcement <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />445 Minnesota Street, Suite 222, St. Paul, MN 55101 <br />651-201-7500 Fax 651-297-5259 TTY 651-282-6555 <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Name of organization <br />Saint John's Church of Little Canada <br />Address <br />[ 380 Little Canada Road <br />Name of person making application <br />Date organized Tax exempt number <br />185L 1 ES 23330 <br />City State Zip Code <br />Little Canada Minnesota I 55117 <br />Business phone Home phone <br />Rev. Thomas Balluff <br />Date(s) of event <br />Saturday, October 11, 2014 <br />Organization officer's name <br />x <br />Rev. Thomas Balluff <br />Add New Officer <br />651 484-2708 <br />1 <br />J <br />Type of organization <br />Club ❑ Charitable ® Religious ❑ Other non-profit <br />City <br />Little Canada <br />Location where permit will be used. If an outdoor area, describe. <br />State Zip <br />Minnesota <br />55117 <br />If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br />If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br />Catholic Mutual Insruance <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUOMI RING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City/County Date Approved <br />City Fee Amount Permit Date <br />Date Fee Paid City/County E-mail Address <br />Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement <br />0L1:1U(s NOTICE: Submit 0115 form to Alcohol and Gambling Enforcement Division 30 days prior to event. <br />PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALLTEMPORARY PERMIT APPROVALS WILL BE SENT <br />BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGf_.TEMPORARYLAPPLICNTION@STATE.MN_US <br />Page 1 of 1 <br />