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(., r©F <br /> UPLIN CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> • ; MOUNDS VIEW, MN 55112 <br /> Partners i s <br /> LICENSE APPLICATION <br /> TEMPORARY LIQUOR LICENSE <br /> Type of Application: Temporary Intoxicating Liquor Special Event <br /> Temporary 3.2 Malt Liquor <br /> } Temporary 3.2 Malt Liquor Special Event/Festival In the Park <br /> Location of Event : 5394 Edgewood Drive (Bel Rae Facility) <br /> 8290 Coral Sea Street("The Bridges Golf Course) <br /> 240 I Highway Ten (City Hall Park) <br /> Date of Event: max. Of 3 days/2 days for Festival in the <br /> ( y y Park) <br /> Date of Application: t go��! Phone: (01 ,-- -)(124, ' `{(0?( <br /> Name of Applicant: vie_ Loki <br /> Name of Business: I`Y\ouP L csft <br /> Address of Business: `ti'le <br /> Does the applicant have a liquor license from the City bf Mounds View? Yes No <br /> If yes, please list the business name on the license: 016 <br /> If no, please list the City in which a liquor license or caters permit is held? i•..)1 <br /> Please list the business name on the license: n3/i4 <br /> Have your ever had a license revoked? nv If yes, attach explanation. <br /> PLEASE SUBMIT EVIDENCE OF THE FOLLOWING: <br /> a. $100,000 bodily injury for each person; <br /> b. $200,000 each common cause; <br /> c. $100,000 Property damage each common cause; <br /> d. $100,000 Loss of Means of Support <br /> e. $200,000 Each Common cause; <br /> f. $300,000 Annual Aggregate <br /> Any policy or insurance pool providing coverage, the City shall be named as an additional insured. <br /> I hereby certify that information provided on this application is true and hereby correct and understand <br /> any misrepresentation made hereby may be ground for denial of this application <br /> Applicant's Full Name: t ' ` L ' LI1I . Date of Birth: / /9 <br /> Applicant's Signature: 1 A' 1_r <br /> For Office Use Only: <br /> Investigation Fee Collected: fj <br /> Fee Collected: <br /> Investigation Completed: <br /> H! <br />