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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 />WWW.DPS.STATEMN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />ti'l+k• <br />STREET ADDRESS <br />5 \5 oi-\e._ CoAckA0.7-p&4. <br />NAME OF PERSON MAKING APPLICATION <br />3cdivv1 <br />DATE ORGANIZED <br />CITY <br />C4 - <br />TAX EXEMPT NUMBER <br />* <br />STATE ZIP CODE <br />ik'w\ 55 I r+ <br />DATES LIQUOR LIQUOR WILL BE SPLD <br />41,0 <br />ORGANIZATION OFFICER'S NAME <br />1kM1A4.) <br />ORGANIZATION OFFICER' NAME <br />BUSLNESS PHONE HOME PHONE <br />( 611— (6S, 34e,R14-- 14)4 <br />TYPE OF 0 t -A TION <br />• A C. A <br />ADDRE <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Location license will be used, Iran outdoor area, describe <br />ve..0.— "/ 1&er-G1-5 <br />CciA,tade <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Will the applicant carry liquor liability insurance? Use, please provide the carrier's name and amount of coverage., <br />• 40 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />Poi <br />CITY/COUNTY <br />CITY FEE AMOUNT <br />DATE FEE PAID <br />DATE APPROVED <br />LICENSE DATES <br />SIGNATURE CITY CLERK Olt COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this forni to the city or county 30 days prior to event. Forward application signed by city anti/or county to the address <br />above. If the application s approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event <br />PS -09079 (05/06) <br />