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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101-5133 <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 I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />DATE ORGANIZED <br />LA 1— <br />TAX EXEMPT NUMBER <br />=1,-zC; <br />STREET ADDRESS <br />NAME OF PERSON MARINO APPLICATION <br />fCHA <br />DATES LIQUOR WILL BE) SULI) <br />ORGANIZATION OFFICER'S NAME <br />/j4Q11.f /r/i> <br />CITY STATE <br />(-1(:A-MI+)9/'0 <br />ZIP CODE <br />BUSINESS PHONE <br />Ai) <br />HOME PHONE <br />(r: j D /m n <br />ORGANIZATION OFFICER'S NAME <br />Dib( 1"1phi /, <br />ORGANIZATION OFFICER'S NAME <br />U <br />)4-)c<'(' <br />Location license will be used. if an outdoor area, describe <br />TYPE OF ORGANIZATION <br />CI t)B CHARITABLE. REI IC;t1QU' nrl-ma IQNPR =17� <br />ADDRESS 11)°1 66 LA tiJOO f J -U- <br />�1 ( f1 C1a.,rJA-l5is, , //fA cT<--1)7 <br />ADDRESS f? /�i.l lr%Oon ,U i- - <br />, ✓+-1/V 55/3 '7 <br />Will the applicant contract for intoxicating liquor service <br />ADDRESS 3ylc 3 /9 - QUI- DI* °3r <br />v/ CN l -, r1 . <br />DLO \_, ZT: <br />c/ q T' -N/ MN `� C' 7 <br />If so, give the name and address of the liquor licensee providing the service. <br />>>/:: 7 <br />/VC <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />APPLICATION <br />) iU D i(av^l r <br />APPROVAL <br />MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />DATE APPROVED <br />LICENSE DATES <br />CITY/COUNTY <br />CITY FEF AMOUNT <br />DATE FEE PAID <br />SIGNATURE, CITY CLERIC OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMI3LING 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 1)ivision wil3 return this application to be used as the License for the event <br />PS -09079 (05/06) <br />