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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) 297-5259 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 />STREET ADDRESS <br />9l) Q®" 3 2 <br />CITY <br />�4 d <br />STATE <br />trM � <br />ZIP CODE <br />5- -S-0 S .� <br />NAME OF PERSON MAKING APPLICATION <br />BUSINESS PHONE=HOME <br />(KIS)e,-(q- (L-( <br />PHONE <br />P ) x-(24' - 1745' <br />DATES LIQUOR WILL BE SOLD -^� <br />/'1e{ 7 -IS' -201 <br />TYPE OF ORGANIZATION <br />T B -0 RELI(ilQl-['.-.)' OTHER N(-)NPK(.)l I <br />ORGANIZATION OFFICER'S NAME <br />C)AK fSA(tLAZ.oCZ <br />ADDRESS <br />1(1206 Gevvev^ WPj, Hu c mo\ s"5-63� <br />ORGANIZATION OF`FICER'S NAME <br />I'ssb� SC"�V�rteCjC(2 <br />ADDRESS <br />606t ktvq Srk tin r0�� <br />ORGANIZATION OFFICER'S NAME <br />Location Iicen: e will be used. If outdoor area, describe <br />_ roclu _ �; �.� � �, Ae1< � eive_v& <br />ADDRESS <br />buc)O , VIAS. --- <br />At W AA, <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />CC>Will <br />the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />f-totis 0-tos 1, 0061 VoC) <br />(�e(-& Ul ufupr� <br />1,000,000 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY,/COUNTY <br />CITY FEE AMOUNT 30 <br />DATE FEE PAID & -7-S; -1 e <br />DATE APPROVED <br />LICENSE DATES <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL 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 />