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Alcohol A Gunhlln(3 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 DAV <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Name of organization Date organized Tax exempt number <br />iT <br />Address <br />I Q4.9 k 'RC _t,e_nii'''jj,, <br />Name of person making applicafg+n <br />Date(s) of e int <br />I l.lA <br />Organization officer's name <br />City State Zip Code <br />-,:\i' —- -- -- 1g�{,t(�c Minnesota �`.j• lli <br />_ _ ___J 1 L_ --SWC -- _ 1 _ --_ l <br />Business phone Home phone <br />1 <br />X / <br />Add Ne Offi�r U ' <br />Location where permit will be used. If an outdoor area, describe. <br />Type of organization <br />Club ❑ Charitable <br />Religious <br />City State <br />❑ Other non-profit <br />Zip <br />k\\(±,_ l (b"Y2�a-��Minnesota _� <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 li bility insurance please provide the carrier's name and amount of coverage. <br />C'���o�tC_ l��lYvI.LCC� �1<LQ:�CC <br />L <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City/County <br />City Fee Amount <br />Date Fee Paid <br />Date Approved <br />Permit Date <br />City/County E-mail Address <br />Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement <br />CLERKS NOTICE, Submit this 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 ALL TEMPORARY PERMIT APPROVALS WILL BE SENT <br />BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGE.TEMPORARYAPPLICATION@STATE.MN.US <br />Page 1 of 1 <br />