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terviffe <br />mn <br />CITY OF CENTERVILLE <br />APPLICATION FOR A 1 TO 4 DAY TEMPORARY /EVENT ON SALE LIQUOR LICENSE <br />(Organization or location limited to 3 permits in a 12 month period) <br />Type or Print Information <br />Name of Organization <br />Centerville Lions Club <br />Date Organized <br />1974 <br />Tax <br />Exempt <br />23- 7391509 <br />Street Address <br />7155 Brian Drive <br />City <br />Centerville <br />State <br />MN <br />jZip Code <br />155038 <br />Name of Person Completing Application <br />Greg Kieselhorst <br />Business Phone <br />612 - 221 -9122 <br />Home <br />Phone <br />Same <br />Dates Liquor Will Be Sold (1 to 4 days) <br />Feburary 18th Or 25th, 2012 <br />Type of Organization <br />■ CLUB 0 CHARITABLE 0 RELIGIOUSO OTHER NON - PROFIT <br />Organization Officer's Name <br />Greg Kieselhorst <br />Address <br />7155 Brian Drive Centerville MN <br />Organization Officer's Name <br />John Thlll <br />Address <br />1375 Mound Trail Centerville MN <br />Organization Officer's Name <br />Tom Wilharber <br />Address <br />6849 Centerville Rd Centerville <br />Location where license will be used. If an outdoor area, describe: <br />On Centerville Lake from Lion Concession Trailer <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the <br />Liquor license providing the service. <br />NA <br />Will the applicant carry liquor liability insurance? If so, the carrier's name and amount of <br />covera e. 2011 -2012 Certificate on File from The Hendrickson Agency Inc. from the Summer Fesitval. <br />PRIOR TO SUBMISSION TO <br />FEE AMOUNT $ �LICENSE DATES <br />DATE FEE PAID <br />Signature of Applicant: Greg Kieselhorst_ A v <br />31 <br />