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at - terviffe <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 Date Organized Tax 23-7391509 <br /> Centerville Lions Club 1974 Exempt <br /> Street Address City State jZip Code <br /> 7155 Brian Drive Centerville MN 155038 <br /> Name of Person Completing Application Business Phone Home <br /> Greg Kieselhorst 612-221-9122 Phone Same <br /> Dates Liquor Will Be Sold (1 to 4 days) Type of Organization <br /> Feburary 21 st, 2015 ■ CLUB ❑ CHARITABLE ❑RELIGIOUS❑ OTHER NON-PROFIT <br /> Organization Officer's Name Address <br /> Greg Kieselhorst 7155 Brian Drive Centerville MN <br /> Organization Officer's Name Address <br /> John Thill 1375 Mound Trail Centerville <br /> Organization Officer's Name Address <br /> Tom Wilharber 6849 Centerville Rd Centerville <br /> Location where license will be used. If an outdoor area, describe: <br /> On Centerville Lake from Lion Concession Trailer and or Canopy <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 /> coverage. 2014-2015 Certificate on File from The Hendrickson Agency Inc.from the Summer Fesitval. <br /> APPROVAL <br /> APPLICATION MUST BE APPROVED BY CITY COUNCIL PRIOR TO SUBMISSION TO LIQUOR CONTROL <br /> CITY OF CENTERVILLE DATE APPROVED <br /> FEE AMOUNT $ LICENSE DATES <br /> DATE FEE PAID <br /> City Clerk <br /> NOTE: Submit to the City of Centerville at least thirty(30)days prior to event. <br /> Signature of Applicant: Greg Kieselhorst_ (��EStC�IdR11- <br /> 37 <br />