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Minnesota Department of Public Safety <br />` ® Alcohol and Gambling Enforcement Division <br />445 Minnesota Street, Suite 222, St. Paul, MN 55101 <br />651-201-7500 Fax 651-297-5259 TTY 651-282-6555 <br />Alcohol & Gambling Enforcement APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Name of organization <br />Date organized Tax exempt number <br />J+u% o Lfnuvs C4ub <br />11 <br />1q7�1— 1 (5-11-9-337-5- <br />5-'1-933 sAddress <br />Address <br />City State <br />Zip Code <br />eQ 60>f 3.21 J <br />I HUMinnesota <br />15S-0 <br />Name of person making application <br />Business phone Home phone <br />O)Af?-k-1 r;_,t- <br />652- 8'Y9 -t 4&,+ 63-!-y29-(%4S <br />Date(s) of event <br />Type of organization <br />Yl'e— -«� �O16 <br />5aClub Charitable [-] Religious Other <br />non-profit <br />Organization officerr'sname <br />City State <br />Zip Code <br />] <br />1 ICNt ae-11 AI <br />LU1.13e r�,a.4-.�. Minnesota <br />,j-/(© <br />Organization officer's name <br />City State <br />Zip Code <br />DAn A pzo2 �� Vic -e- Fe <br />u Cl Minnesota <br />5x63$ <br />Organization officer's name <br />City State <br />Zip Code <br />-SCr (x,,-__ I4u2T Se m <br />Nu Minnesota <br />,,5-5-63g <br />Organization officer's <br />City State <br />Zip Code <br />�name <br />I%AfLX Ae"t•-S 5Z'i -r _ ug2er <br />A* b Minnesota <br />where permit will fbe used. If an outdoor area, describe. <br />Locationr <br />AgZPA f.�S C.S Q13 <br />bdo,-, AZ4-tk\,50 fe_nCec(in <br />If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br />KA <br />If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br />bolnS e(v65 �Ycif�v rouwl 00:0 ,000 <br />West (3er\ek SV\s <br />lj 600, Ono <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City or County approving the license Date Approved <br />Fee Amount Permit Date <br />5 -3i -1(o <br />Date Fee Paid City or County E-mail Address <br />City or County Phone Number <br />Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement <br />CLERKS NOTICE: Submit this form to Alcohol and Gambling Enforcement Division 30 days priorto event. <br />ONE SUBMISSION PER EMAIL, APPLICATION ONLY. <br />PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY PERMIT APPROVALS WILL BE SENT <br />BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGE.TEMPORARYAPPLICATIONOSTATE MN US <br />