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Name organization Date organized Tax exempt number <br />Hugo Lionss Club <br />Jan 1,1975 ... . W 5423375 <br />o <br />Address <br />PO Box 321 <br />City State Zip Code <br />_........ __ _ <br />Hugo Minnesota 55038 <br />Name of person making application <br />Dan Balthazor <br />Business phone Home phone <br />�������-� 651 777-6924� 2-910 0994 <br />Date(s) of event <br />Type of organization ❑ Microdistillery ❑ Small Brewer <br />5-10-2019 <br />❑X Club ❑ Charitable ❑ Religious ❑ Other non-profit <br />Organization officer's name <br />Dan Balthazor <br />w <br />City State Zip Code <br />Hugo Minnesota 55038 <br />m .................... W....... ... <br />g officer's name <br />Organization <br />Crai g Tracy <br />City State Zip Code <br />Hugo Minnesota 55038 <br />Organization o Icer s name _ <br />Jason Schwie er <br />g_,._... <br />_ <br />yg City StateZip Code <br />� Hugo Minnesota55038 <br />.. <br />Organization rt officer'name _ <br />Mark He <br />...._._ <br />State <br />_ Zip Code <br />g nesota �55038 <br />� �Hu o Mln �mwm mmm <br />Location where permit will be used. If an outdoor area, describe. <br />Grundhofer's Old Fashion Meats <br />15449 Forest Blvd. Hugo, MN. 55038 5-10-2019 11 am to 2pm. <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 />Lion's Club International 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 license _........_ Date Approved <br />15 <br />Fee Amount .._ Permit Date <br />Date Fee Paid City or County E-mall Address <br />C95t--7GZ-43ts <br />¢' 71 City or County Phone Number _._.. <br />Signature City Clerk or County Official -.......... Approved Director Alcohol and Gambling Enforcement <br />CLERKS B07CE: Sulbmit fl-Js Form to McoIh6 and Varrbllrng i iforcernent Dhdslon 30 days prr or to event, <br />O'iL1111911 CWylllll'1611111P"'y5'IIIIOIIIL 1114sIIIIIlE1111i1IIIiIIIIWVAW'i µ Alll! BIIL.JIIICA"'W"'W1"1111P'1 OIINLA. <br />W IIIIwLALllll IIIIr Rf1VIIIIIIILL A VAllll.11llllll.J IIIRIIII i'ytAWL AIIW.IIL11111111111111'."'" L W°°01114y Llllh°IIIIIIIIIIIII W lIIIIIAII W BLIIMJIII'K'iBAtL Wwy1L,W," IIII AWIWII'y()VAW.5 AIIIILI11E SIIIIIIICJ"W <br />BACK VW. LIIOLI111WBY VW WVL�1w1OVO III V 1O AGII!11111 " <br />f A W.ION <br />@S ("AWL IIgJ yj <br />