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Minnesota Department of Public Safety' <br />I Alcohol and Gambling Enforcement Division <br />61 445 Minnesota Street, Suite 222, St. Paul, MN 55101 <br />651-201-7500 Fax 651-297-5259 TfY 651-282-6555 <br />Alcohol & Gambling Enforcement APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPnOARY ON -SALE LIQUOR LICENSE <br />Name of organization _ Date organized Tax exempt number <br />Hugo Lions Club 1975 5423375 <br />Address City State Zip Code <br />Po Box 321 Hugo MN 55038 <br />Name of person making application Business phone Home phone <br />Dan Balthazor _ 651-777-6924 612-910-0994 <br />Date(s) of event Type of organization ❑ Microdistillery ❑ Small Brewer <br />6-6-2019 thru 6-9-2019 X❑ Club ❑ Charitable ❑ Religious ❑ Other non-profit <br />Organization officer's name <br />City State <br />Zip Code <br />Dan Balthazor <br />Hugo _:�] I MN 1 <br />155038 <br />Organization officer's name <br />City State <br />Zip Code <br />Craig Tracy <br />Hugo MN <br />55038 <br />Organization officer's name <br />City State <br />Zip Code <br />IJason Schwieger <br />_ <br />Hugo MN <br />55038 <br />Organization officer's name <br />City State <br />Zip Code <br />Mark Heifort <br />Hugo MN <br />55038 <br />Location where permit will be used. If an outdoor area, describe. <br />Lions Park Hugo, MN. <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 />Lions Club Internation 1,000,000.00 <br />West Bend Mutual Ins. 1,000,000.00 <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City or County approving the <br />ount <br />Date Fee Paid <br />Date Approved <br />City or County E-ma <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 />BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/COUNTY TO AGE.TEMPORARYAPPLICATION STATE.MN.US <br />