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II�P~��HS of/J1_.Y <br />�`�MINN <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) 297-5259 TTY (651) 282-6555 <br />W WW.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A I 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 />C I u% <br />/Y,7s— <br />S9-), 337-5-- <br />STREET ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />R Rod 3 <br />(j(n <br />M �\ <br />�Q—n?.r <br />NAME OF PERSON MAKING APPLICATION <br />1V,a,f�_H eT -G P-"r <br />BUSINE PHONE <br />0) `f 2 er / 74,r- <br />HOME PHONE <br />62) L(4 e'f <br />DATES LIQUOR WILL BE SOLD t�� 2d <br />TYPE OF OR ' • TION <br />- <br />I TAB RE I ( I f Nf <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />t2(4yv Fto"`�k (2C� <br />Try <br />CO S. (-Ake tAA 0, 5257lrO <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS ; Lvzo& Gfv\evA LJ••y <br />I4"L QAVzOQ, <br />t�e> M\,- ss63s&- <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS .351 g° (C'ISXLA !9-C- <br />� <br />Location license will he usetI . If an outdoor area, describe <br />rA r 1( C-ItZ (cK — F (r U <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />tl\ O <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />L1CC9V15 �� tJ�j �t1'�Llfl-"sCcou►�"� (�C �jQd <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY ��C��r�t�ncn`'[� <br />DATE APPROVED_ <br />3 <br />CITY FEE AMOUNT t S , 0 (5 <br />LICENSE DATES <br />DATE FEE PAID <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 />