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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 131, St. Paul MN 55101-5133 <br />(651) 201-7507 Fax (651) 297-5259 TTY (651) 282-6555 <br />WWW.DPS.STATE.MN.31S <br />APPLICATION A1 -1D PERMIT <br />FOR A I TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />I NAME OF ORGANIZATION <br />.f\A.Dp, apt <br />SFREE1• ADDRIISS <br />A5"i"- <br />DATE ORGANIZED TAX (EXEMPT NUMBER <br />CITY S"17t'(g ZIP CODE <br />NAME OF PERSON MAILING APPLICATION <br />(-IA f. L. /1:/Ir Q./I L/ar.1;• <br />DATES LIQUOR WILL 13E SOOT <br />:T \ A; J. A t., 3l <br />ORGANIZATION ION OI 1 ICER S NAME <br />ORGANIZA"I'iON OFFICER'S NA <br />BUSINESS PHONE BIOME PHONE <br />-2 <br />TYPE OF ORGANIZATION" <br />102U.13 Sal/3RITABLL.__ kEL LG±OtJS 0 Lt1LR1LGNPi{f+I f 3 <br />I ADDRESS L -;i/ .t -,..;:x.,? %! v, - <br />1 <br />• <br />L. 11-I-II—k: (.103 -ii,\ 74; it 1 <br />• <br />Ml's 'ADDRESS / /3.5c, /:\t%1�.. <br />ORG ANI L t.'l IGVt Ol FI CE R'S 1vA h41 <br />^(j5-1�✓�i His/AI,F- <br />I: i • <br />I ADDRESS J LI j .X /l+ (FW'& C.)-11 <br />t -/Al \: /s t ri l / C, l ) 7 i y -4/L; 433. ./' 7 I <br />I..ecation license will be used. If an outdoor arch, describe <br />/.i-(-(?. L. (jt/ ;\(>i-\ RAH <br />win the applicant contact for intoxicating lig OW scngCC? If so, give the name and address of the liquor licensee providing the service. <br />1� <br />Pi, 1 the applicant carry liquor habil ity Insurance? If se, please provide. the carries' s name and amount of coverage.. <br />APPLICATION <br />fACP <br />1'PROVAL <br />(1ST BE APPROVED BY CITY OR COUNTY BEFORE- SUBMI•[TING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY_— <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />DATE APPROVED <br />LICENSE DATES <br />SIC:NAIL:RE. CITY CLERIC OR (:OUNTY OFhICIAI. APPROVED DIRECTOR ALCOHOL. AND C1AM931,I:NG E:N'PORIm::>5ItNr <br />NOTE: Submit this form to the city or county 30 days prior m event, Forward application signed by city and/or county to the address <br />above. If (IIC ApphCN lion is Ap srovtd the Alcohol and Gambling Enforcement Di�is on will return Ibis Apsn cation to bo H5H'. i..cOle L.Ir<.n.r for tlrc ;cnt <br />PS -(29T),: 05106; <br />2 <br />