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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 Co- 7 -2 O t(a <br />651-201-7500 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 />wia 6,?RN�f, -V`0 /\ <br />-,T� V ,S V,,A-tcL- <br />=f <br />Name of organization <br />Date organized Tax exempt number <br />tYliv Nosh.. S+Ctc (-,a V-ocl`0 <br />soCi�+;� <br />1189Jossq-73S-Ce <br />Address <br />City State Zip Code <br />g of q9 <br />S+• PA. k-1 <br />MN SS I l l <br />Name of person making application <br />Business phone Home phone <br />cJ A c o b (o v -- t' n <br />CSS I - LM Z - ®/CSD,( <br />1 (oSl ' yN Z - 9(0 <br />Date(s) of event <br />Type of organization <br />J k,. -A 30 d 31 1 70 1 fo <br />E] Club 0 Charitable E] Religious Other non-profit <br />Organization officer's name <br />City State Zip Code <br />J h �' f-4-1",-) <br />CA y Q ✓,, I MN �$ I Z L <br />Organization officer's name <br />City State Zip Code <br />MN <br />D <br />Organization officer's name <br />City State Zip Code <br />MN <br />Organization officer's name <br />City State Zip Code <br />—� MN <br />Location where permit will be used. If an outdoor area, describe. <br />u a d IAV Db C__ A-re✓c c>_ 1 4v5 <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 />JC0,1 i E- 1A SuraviC< � f 000 , U()0 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />1�v <br />of �JLga <br />City or County approving the license Date Approved <br />-3G_U0 <br />Permit Date <br />(o-IS-I(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 prior to 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 />BACKVIAEMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGE.TEMPORARYAPPLICATION@STATE.MNUS <br />