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Minnesota Department of Public Safety Attachment A <br /> Alcohol and Gambling Enforcement Division <br /> 445 Minnesota Street,Suite 1600, St. Paul, MN 55101 <br /> 651-201-7507 TTY 651-282-6555 <br /> Alcohol&Gambling Enforcement APPLICATION AND PERMIT FOR A 1 DAY <br /> TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br /> Name of organization Date of organization Tax exempt number <br /> MATTER 08/16/2022 6622015 <br /> Organization Address(No PO Boxes) City State Zip Code <br /> 7005 Oxford St St.Louis Park Minnesota 55426 <br /> Name of person making application Business phone Home phone <br /> Victor Salamone 952-500-8652 <br /> Date(s)of event Type of organization ❑ Microdistillery ❑ Small Brewer <br /> 9/27/2022 ❑ Club X❑ Charitable ❑ Religious ❑ Other non-profit <br /> Organization officer's name City State Zip Code <br /> Quenton Marty St.Louis Park Minnesota 55426 <br /> Organization officer's name City State Zip Code <br /> Jeremy Newhouse St.Louis Park Minnesota 55426 <br /> Organization officer's name City State Zip Code <br /> Minnesota <br /> Location where permit will be used. If an outdoor area,describe. <br /> Boston Scientific 4100 Hamline Ave N Arden Hills MN 55112 <br /> Outside Building 3 Parking lot,next to the tent hosting the community service activity <br /> If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br /> OMNI Brewing Company,9462 Deerwood Lane N,Maple Grove,MN 55369 <br /> If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br /> MATTER's insurance carrier that is providing the liquor liability coverage:Swiss Recorp Solutions Elite Insurance <br /> Liquor liability coverage limits of$1 million per claim&$1 million aggregate <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 /> Fee Amount Permit Date <br /> Event in conjunction with a community festival ❑ Yes ❑ No <br /> City or County E-mail Address <br /> Current population of city <br /> Please Print Name of City Clerk or County Official Signature City Clerk or County Official <br /> CLERKS NOTICE: Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to event <br /> No Temp Applications faxed or mailed. Only emailed. <br /> ONE SUBMISSION PER EMAIL,APPLICATION ONLY. <br /> PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY <br /> PERMIT APPROVALS WILL BE SENT BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY <br /> CITY/COUNTY TO AGE.TEMPORARYAPPLICA TION@STA TE.MN.US <br />