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O }VAD <br /> CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> „ MOUNDS VIEW, MN 55112 <br /> 'a71 <br /> ilayu-Paan ', <br /> LICENSE APPUCATIOI4 <br /> TEMPORARY LIQUOR LICENSE <br /> Type of Application: Temporary Intoxicating Liquor Special Event <br /> Temporary 3.2 Malt Liquor <br /> A Temporary 3.2 Matt Liquor Special EventiFrtival In the Park <br /> Location of Event: 5394 Edgewood Drive(Bel Rae Facility) <br /> 8290 Coral Sea Street("'The Bridges Golf Course) <br /> 2401 Highway Ten(City Hall Park) <br /> Date of Event: (max. Of 3 days/2 days for Festival in the Park) 1J14 92 <br /> Date of Application: 5)1 a)qs2 on I R(0-4(4 c <br /> Name of Applicant: C Ke, • t 0 -. t <br /> Name of Business: 1'1 ounci .)U Pu_c) cQ un I J Dm <br /> Address of Business: Qs 9 `<h 0 l 1 -Dirt u-e. <br /> Nounck 0) eL / ncYA .55) ) <br /> Dos the applicant have a liquor license from the City of Mounds View? Yes X No <br /> If yes, please list the business name on the license: <br /> If no, please listthe Gly in which a liquor license or cram permit is held? <br /> Please list the business name on the license: <br /> Have your ever had a license revoked? LX) If yes, attach explanation, <br /> PLEASE SUBMIT EVIDENCE OF THE F011OWING: <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 Crty shall be named as an additional insured. <br /> I hereby certify that information provided on this application is true and hereby correct and <br /> understand any misrepresentation made herebybymay be ground for denial of this application <br /> �'�� <br /> Applicant's Full Name: ,.iy/1l`�7 re✓(�i1 1,e,2 Date of Birth: 4 / %g J/`/7 <br />