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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />445 Minnesota Street, Suite 1600, St. Paul, MN 55101 <br />651-201-7507 TTY 651-282-6555 <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br /> <br />Name of organization Date of organization Tax exempt number <br />Organization Address (No PO Boxes)City State Zip Code <br />Name of person making application Business phone Home phone <br />Date(s) of event <br />Club Charitable Religious Other non-profit <br />Type of organization <br />Organization officer's name City State Zip Code <br />Organization officer's name City State Zip Code <br />Organization officer's name City State Zip Code <br />Location where permit will be used. If an outdoor area, describe. <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 />City or County approving the license Date Approved <br />Fee Amount Permit Date <br />Signature City Clerk or County Official <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City or County E-mail Address <br />CLERKS NOTICE: Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to event <br />No Temp Applications faxed or mailed. Only emailed. <br />ONE SUBMISSION PER EMAIL, APPLICATION ONLY. <br />PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY <br />PERMIT APPROVALS WILL BE SENT BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY <br />CITY/COUNTY TO AGE.TEMPORARYAPPLICATION@STATE.MN.US <br />Microdistillery Small Brewer <br />Please Print Name of City Clerk or County Official <br />Event in conjunction with a community festival Yes No <br />Current population of city <br />Lake Elmo Rotary 06/30/2005 20-2814804 <br />2945 Lake Elmo Ave Lake Elmo MN 55042 <br />Elizabeth Niehaus 651-283-8794 <br />9/13/25 <br />Pamela Baker Lake Elmo MN 55042 <br />Temre Pugh Lake Elmo MN 55042 <br />Rita Shephard Lake Elmo MN 55042 <br />Lions Park in Lake Elmo, next to the park pavillion <br />n/a <br />Westchester Surplus Lines Ins <br />$2,000,000/$4,000,000 <br />City of Lake Elmo <br />$25/waived 9/13/25 <br />jjohnson@lakeelmo.gov <br />13,756