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Name of oraanization <br />t Brewstillery <br />Address <br />1744 Terrace Dr <br />Name of person making a <br />Bartley Blume <br />Dates) of event <br />6/24/2021 <br />nization officer's name <br />rtley Blume <br />Oraanization officer's name <br />on officer's name <br />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 Fax 651-297-5259 TTY 651-282-6555 <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Date organized Tax exempt number <br />June 11, 2011 45-2650832 <br />City State Zip Code <br />Roseville MN 55113 <br />Business phone Home phone <br />651-233-3843 —� 1 <br />Type of organization ❑ Microdistillery ❑Small Brewer <br />❑X Club []Charitable ❑ Religious [:]Other non-profit <br />City State _ Zip Code <br />Roseville MN 55113 <br />City State Zip Code <br />MN—� <br />City State _ Zip Code _ <br />�— MN <br />Location where permit will be used. If an outdoor area, describe. <br />Lauderdale Community Park, 1885 Fulham St, Lauderdale, MN 55113 <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 />West Bend Insurance Company <br />Aggregate Limit: $2,000,000, Each Common: $1,000,000 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City of Lauderdale <br />or County approving t <br />C <br />N/A <br />Date Fee Paid <br />Signature City Clerk or County Official <br />e license <br />jim.bownik@la <br />City or County <br />651-792-7650 <br />City or County Phone Number <br />Please Print Name of City Clerk or County Official <br />CLERKS NOTICE: 5ubmifi this form to Alcohol and Gambling Enforcemenfi Division 30 days prior to event. <br />ONE SUBMISSION PER EMAIL, APPLICATION ONLY. <br />PLEASE PROVIDE AVALID 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 />