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zOFPU <br />Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101-5133 <br />(651) 201-7507 Fax (651) 29765259 TTY (651) 282-6555 <br />W W W.DPS. STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />HU U Ltov,S C(y6 <br />I�(�7S <br />Fee S/—Oly5oS3 <br />stAte 5y9-337r <br />STREET ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />Pa (Iwr D,1 <br />H USO <br />rn <br />5",5003Fs <br />NAME OF PERSON MAKING APPLICATION <br />BUSINESS PHONE <br />HOME PHONE <br />I(hA2K <br />(6a) vot -( iyy <br />(-I) 92C( -74 s- <br />DATES LIQUOR WILL BE SOLD tc, <br />TYP , OF ORGANIZATION <br />TABLE RELIGIOUS OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />DRESS 606 [ (I-(4Sr IiI <br />JASov\ Sa w%.P_5em <br />R,)5o fynlk 9�S-63 �,- <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />l ��l'f© �=1on,a R�4 <br />C1� �5 '��,oc� <br />GUwzk-� fkAR Lk 4hrt 5YI16 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />R\A' - Ne; 4o7_T <br />�b g3ok �26 <br />Location license will be used. If an outdoor area, describe <br />U01AS PR2k - I�ku� o <br />Will the applicant contract for intoxicating liquor service? If <br />so, give the name and address of the liquor licensee providing the service. <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />L-loKS <br />Ctu6s �'te2rt }ro�4l <br />tr UO(3)606 <br />2SC$�v�dL Mum\ ^C.�.g Ca <br />I�ac�ojoto <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY <br />DATE APPROVED <br />/ <br />CITY FEE AMOUNT U <br />LICENSE DATES <br />DATE FEE PAID u - I <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the License for the event <br />PS-09079 (05/06) <br />